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USMLE
Pediatrics IV
A 3-month-old infant is hospitalized for repair of a cleft lip. Following surgery, the baby returns to the unit with a Logan bow in place. The baby is awake and beginning to whimper. The baby’s color is pink, and pulse is 120 with respirations of 38. An IV is ordered in the baby’s right hand at 15 cc per hour. The fluid is not infusing well. Her right hand is edematous. The jacket restraint has loosened, and one arm has partially come out. What is the priority nursing action?
Explanation
ExplanationPriority care following cleft lip repair is to keep the child from pulling at the lip repair site. The IV is probably infiltrated. Further assessment of the IV should be done after the restraint has been replaced. The vital signs are normal. Checking to see if the baby has voided is not a priority measure.
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