Which intervention should the nurse implement after cleft lip repair?

• A. Feed the infant with a Breck feeder and then rinse her mouth.
• B. Report bleeding from the suture site to the primary health care provider.
• C. Administer an analgesic as needed without evaluating the child.
• D. Remove sutures at home if crying.

Answer: (B)

Bleeding from the suture line after cleft lip repair is a danger signal that requires prompt clinician involvement. If bleeding occurs, it could indicate wound disruption, vessel injury, or hematoma formation, all of which can rapidly worsen and potentially threaten the infant’s airway or lead to infection. The nurse’s role is to alert the primary health care provider right away so the surgeon can assess the wound and determine the appropriate intervention to stop the bleeding and prevent further complications.

Other actions don’t address a potential post-op complication. Administering analgesics without assessment can mask signs of bleeding or evolving problems. Removing sutures at home is unsafe and beyond the nurse’s scope of practice. While feeding methods and comfort measures are important for recovery, they don’t replace the need for immediate evaluation when bleeding is present.