A 2 month-old infant has both a cleft lip and palate which will be repaired in stages. In the immediate postoperative period for a cleft lip repair, which nursing approach should be the priority?

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Question 1 of 5

A 2 month-old infant has both a cleft lip and palate which will be repaired in stages. In the immediate postoperative period for a cleft lip repair, which nursing approach should be the priority?

Correct Answer: C

Rationale: Suture line care prevents infection, a priority post-cleft lip repair.

Question 2 of 5

The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What is the priority nursing diagnoses at this time?

Correct Answer: D

Rationale: Prolonged rupture increases infection risk, a priority post-delivery.

Question 3 of 5

On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse's initial response should be to

Correct Answer: B

Rationale: A personal introduction and escort reduce anxiety and build trust.

Question 4 of 5

A client has just been admitted with portal hypertension. Which nursing diagnosis would be a priority in planning care?

Correct Answer: B

Rationale: Hemorrhage risk from esophageal varices is life-threatening in portal hypertension.

Question 5 of 5

Which of these variations in the newborn results from the presence of maternal hormones?

Correct Answer: A

Rationale: Breast engorgement in newborns is due to maternal estrogen exposure.

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