The nurse is planning postoperative care for an infant after a cleft lip repair. Which of the following should the nurse include in this infant's plan of care?
1. Prone positioning
2. Suctioning with a tonsil tip (Yankauer) device
3. Supine or side-lying positioning
4. Avoidance of soft elbow restraints
3
Rationale:
1. The prone position should be avoided to prevent tension or rubbing of the suture line.
2. 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.
3. Integrity of the suture line is essential for postoperative care of cleft lip repair. The infant should be placed in a supine or side-lying position to avoid rubbing the suture line on the bedding.
4. Soft elbow restraints should be used to prevent the infant from touching the surgical area.
Nursing Process: Planning
Client Need: Safe, Effective Care Environment
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