A nurse is contributing to the plan of care for a 2-month-old infant who has just undergone cleft palate repair. The nurse should contribute which of the following interventions to the client's plan of care?

A. Feed the infant half-strength formula for the first 48 hr: Feeding guidelines do not typically require diluted formula unless directed by the surgeon. B. Remove elbow restraints while the infant is sleeping: Elbow restraints should remain in place to prevent the infant from touching the surgical site, even during sleep. C. Administer pain medication PRN for the first 48 hr: Pain medication should be administered on a regular schedule initially to control pain effectively. D. Keep the infant in a side-lying position: This position helps protect the surgical site and minimizes the risk of aspiration.