A nurse is caring for an infant who is postoperative following repair of a cleft palate. Which of the following is an appropriate action by the nurse?
Explanation & Rationale
A. Apply elbow immobilizers to both arms: Elbow immobilizers prevent the infant from touching or disrupting the surgical site with their hands. This protects the cleft palate repair and promotes proper healing during the immediate postoperative period. B. Gently cleanse the surgical site with sterile gauze: The cleft palate repair is located inside the oral cavity, which should not be manually cleansed with gauze. Irrigation or direct manipulation may damage the sutures or introduce infection. C. Place the infant in a supine position: Infants are typically placed on their side or abdomen postoperatively to facilitate drainage and reduce aspiration risk. Supine positioning can increase the risk of aspiration due to oral secretions. D. Offer a pacifier with glucose syrup: Pacifier use is discouraged after cleft palate surgery because the sucking motion can disrupt the surgical repair. Glucose syrup is also not recommended due to risk of aspiration and dental concerns.