Question: An infant has just returned to the nursing unit after a surgical repair of a cleft lip on the right side. The nurse places the infant in which best position at this time?
1. Prone position
2. On the stomach
3. Left lateral position
4. Right lateral position
Rationale: A cleft lip is a congenital anomaly that occurs as a result of failure of soft tissue or bony structure to fuse during embryonic development. After cleft lip repair, a nurse avoids positioning an infant on the side of the repair or in the prone position because these positions can cause rubbing of the surgical site on the mattress. The nurse positions the infant on the side lateral to the repair or on the back upright and positions the infant to prevent airway obstruction by secretions, blood, or the tongue. From the options provided, placing the infant on the left side immediately after surgery is best to prevent the risk of aspiration if the infant vomits.
Test-Taking Strategy: Eliminate options 1 and 2 because they are comparable or alike positions. Consider the anatomical location of the surgical site and not the strategic words right side to direct you to the correct option from the remaining options. Review postoperative positioning techniques after cleft lip repair if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process-Implementation
Content Area: Child Health-Gastrointestinal/Renal
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed., p. 1095). St. Louis: Saunders.
This week’s NCLEX exam practice question came from:
Silvestri: Saunders Comprehensive Review for the NCLEX-RN Exam, 5th Edition, Chapter 40, pg 481, question 409
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