The nurse plans care for a pediatric client who has just undergone a cleft palate repair. Which of the following interventions should the nurse include in the plan of care? Select all that apply.

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A cleft palate is a malformation of the roof (palate) of the mouth occurring from incomplete fusion of the palatine bones and maxilla during fetal development. Cleft palate causes an opening (cleft) in the mouth into the nasal cavity, which leads to difficulty in sucking and feeding. Clients with cleft palate typically undergo surgical repair between age 6-24 months. Postoperative nursing interventions for clients with a cleft palate repair include: Implementing pharmacological and nonpharmacological pain management (eg, encouraging caregiver soothing), as uncontrolled pain leads to crying, which stresses the surgical site and promotes hemorrhage (Option A) Positioning the child in an upright, supine position, particularly after feedings, to prevent airway compromise and obstruction from secretions and/or feedings (Option C) Utilizing elbow restraints to prevent the child from disrupting the surgical site by placing hands or objects into the mouth, and monitoring skin and neurovascular status by removing elbow restraints per agency policy (Option D) (Options B and E) Hard objects (eg, utensils, tongue depressors, pacifiers, straws) should not be placed into the mouth as they may damage the surgical site, which can lead to hemorrhage. Educational objective: Following cleft palate repair, the nurse should position the client supine with elevated head of bed, implement pain reduction measures, and remove elbow restraints per facility policy for skin and neurovascular assessment. To prevent damage to the surgical site, hard objects should not be placed into the mouth.

The Nurse Plans Care for a Pediatric Client Who Has