A 2-week-old patient born with a myelomeningocele is to undergo surgical repair of this defect. Which nursing action is of the highest priority in her preoperative care?
Monitoring for apical pulse every hour.
Maintaining the patient in a prone position.
Providing the patient sensory stimulation.
Keeping a strict record of the patient's intake and output.
The Correct Answer is A
Choice A rationale:
Monitoring the apical pulse is of the highest priority for a patient with a myelomeningocele preoperatively. A myelomeningocele is a neural tube defect that can lead to neurologic complications. Monitoring the apical pulse every hour helps detect any signs of cardiac distress or neurological compromise, allowing prompt intervention.
Choice B rationale:
Maintaining the patient in a prone position is not the priority in this situation. While positioning can be important, monitoring vital signs takes precedence over positioning.
Choice C rationale:
Providing sensory stimulation is important for the patient's overall well-being, but it's not the highest priority preoperatively. Monitoring vital signs and assessing for potential complications take precedence.
Choice D rationale:
Keeping a strict record of the patient's intake and output is important for general care, but it's not the highest priority in the immediate preoperative period. Monitoring vital signs and detecting signs of distress come first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
If the pancreatic enzymes are effectively aiding in digestion for a patient with cystic fibrosis, the expected outcome would be improved absorption of nutrients and fats. This would result in normal stool consistency and color. Cystic fibrosis often impairs the pancreas' ability to produce sufficient digestive enzymes, leading to malabsorption and fatty stools. Therefore, observing normal stool consistency indicates that the enzymes are working adequately.
Choice B rationale:
The color of the patient's sclerae (the white part of the eyes) is not directly related to the effectiveness of pancreatic enzymes in cystic fibrosis. Scleral color can be affected by various factors such as jaundice, liver function, and blood disorders.
Choice C rationale:
Moist buccal mucosa (inner lining of the mouth) is not a specific indicator of the effectiveness of pancreatic enzymes. This observation could be influenced by hydration status and overall oral care.
Choice D rationale:
Glucose presence in urine is more related to diabetes management rather than the effects of pancreatic enzymes in cystic fibrosis. The absence of glucose in urine does not provide information about the efficacy of these enzymes.
Correct Answer is B
Explanation
Choice B rationale:
After cleft palate repair, infants should be fed pureed or soft foods to prevent trauma to the surgical site and facilitate healing. These textures minimize the risk of injury and avoid strain on the repaired area.
Choice A rationale:
Allowing the child to self-feed with a spoon can introduce solid textures prematurely and pose a risk of disrupting the surgical repair.
Choice C rationale:
Using a cup with a straw might cause suction that could negatively impact the healing surgical site, increasing the risk of complications.
Choice D rationale:
Restricting breastfeeding is not necessary for cleft palate repair. However, positioning adjustments may be needed to facilitate effective breastfeeding while minimizing stress on the surgical area.
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