The nurse is planning postoperative care for an infant after a cleft lip repair. Which intervention should the nurse include in this infant's plan of care?
1. Suctioning with a tonsil tip (Yankauer) device
2. Using a pacifier to reduce straining the suture line with crying
3. Supine positioning
4. Frequent breast or bottle feeding
3
Rationale 1: A tonsil tip (Yankauer) suction device is made of hard plastic, and, if used, could cause trauma to the suture line. Suctioning should be done with a small, soft-suction catheter.
Rationale 2: The child is not allowed to have anything in her mouth, so pacifiers are not acceptable. The child should be soothed by holding and cuddling.
Rationale 3: Integrity of the suture line is essential for postoperative care of cleft lip repair. The infant should be placed in a supine position to avoid rubbing the suture line on the bedding.
Rationale 4: In the immediate postoperative period, the child is fed by eye dropper or rubber-tipped asepto syringe to prevent damage to the suture line.
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