During the first few days after surgery for cleft lip, which intervention should the nurse do?
a. Leave infant in crib at all times to prevent suture strain.
b. Keep infant heavily sedated to prevent suture strain.
c. Remove restraints periodically to cuddle infant.
d. Alternate position from prone to side-lying to supine.
ANS: C
The nurse should remove restraints periodically, while supervising the infant, to allow him or her to exercise arms and to provide cuddling and tactile stimulation. The infant should not be left in the crib, but should be removed for appropriate holding and stimulation. Analgesia and sedation are administered for pain. Heavy sedation is not indicated. The child should not be placed in the prone position.
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