After surgical repair of a cleft lip, what is a key nursing action to monitor for infection?

Assess lung sounds

Check temporal artery temperature

Monitoring for infection following a surgical repair of a cleft lip is crucial due to the surgical intervention and the potential for complications. Checking the temporal artery temperature is significant in this context because it provides an accurate reflection of the patient's systemic temperature and can indicate the presence of infection. Elevated temperature is a common sign of infection and can assist in the early identification of complications associated with surgery.

The other choices address physiological functions that are less directly related to monitoring for infection in this specific postoperative context. Assessing lung sounds is more relevant for respiratory concerns rather than for potential infections related to the surgical site. Monitoring pulse oximetry primarily focuses on oxygenation status rather than signs of infection. Evaluating bowel sounds is important in surgical contexts related to abdominal surgeries but is not applicable in monitoring for infection at the site of a cleft lip repair. Thus, checking the temporal artery temperature stands out as the most pertinent nursing action for infection surveillance after this type of surgery.

Monitor pulse oximetry

Evaluate bowel sounds

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