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:
Refeeding any thrust out food to the baby is incorrect as it increases the risk of choking and aspiration. Parents should discard food that the baby has pushed out to prevent potential harm.
Choice B rationale:
Avoiding the use of skin lubricants on the baby is appropriate as these products might irritate the baby's sensitive skin.
Choice C rationale:
Suctioning the baby's nose before feedings is important to ensure proper breathing and effective feeding, especially in infants with Down Syndrome who may have nasal congestion.
Choice D rationale:
Using minimal soap when bathing the baby is appropriate to prevent skin irritation. Babies have delicate skin, and excessive soap can lead to dryness and discomfort.
Correct Answer is A
Explanation
"My child will no longer be affected by this condition once we start physical therapy.”.
Choice A rationale:
Cerebral palsy is a lifelong condition that affects muscle control and movement. Physical therapy can improve functionality, but it cannot completely cure or eliminate the condition. This statement demonstrates a misunderstanding of the nature of cerebral palsy.
Choice B rationale:
Choice B is accurate. Cerebral palsy management often involves a multidisciplinary approach including physical therapy, occupational therapy, and other interventions to achieve the best outcomes.
Choice C rationale:
Choice C is correct. There are indeed various treatment options for cerebral palsy, including medications, surgeries, and braces, depending on the severity and specific needs of the individual.
Choice D rationale:
The statement in Choice D is accurate. Inclusion and socialization with typically developing peers is encouraged, and schools often promote interactions among children with and without disabilities.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today