A new graduate nurse is caring for an infant with myelomeningocele before surgical intervention. Which action will demonstrate the need for further education by their preceptor?

Keeping the mass uncovered and dry.

Preventing cold stress using an isolette or radiant warmer

Placing the infant in prone/semi-sidelying position and repositioning every 2 hrs.

Encouraging parents to touch and interact with their infant

Answer and Explanation

The Correct Answer is A

A. The myelomeningocele should be kept moist and covered with a sterile, non-adherent dressing to protect the exposed tissue. Leaving it uncovered could increase the risk of infection.

B. Preventing cold stress is essential to maintain the infant's body temperature and reduce stress on the body.

C. Positioning the infant prone helps avoid pressure on the sac and prevents injury.

D. Encouraging parental interaction is beneficial for bonding and emotional support.

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Correct Answer is ["A","B","C","E"]

Explanation

A. Hypotension is common due to neurogenic shock in spinal cord injuries.

B. Hyperthermia can result from loss of autonomic control of temperature regulation.

C. A weakened gag reflex is possible with cervical spinal injuries, increasing the risk of aspiration.

D. Polyuria is not a common complication directly related to spinal cord injury.

E. Absence of bowel sounds can indicate paralytic ileus, a potential complication in spinal cord injuries.

A. Perform a neurovascular assessment. B. Apply an ice pack to the casted leg. C. Provide reassurance to the client and parents. D. Explain the discharge instructions to the client and parents.

Correct Answer is A

Explanation

A. A neurovascular assessment is priority to ensure circulation is adequate in the affected limb, preventing complications like compartment syndrome.

B. Ice application can help reduce swelling but is secondary to ensuring circulation.

C. Providing reassurance is supportive but not as critical as physical assessment.

D. Discharge instructions are important but can follow the neurovascular assessment.

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A new graduate nurse is caring for an infant with myelomeningocele before surgical intervention. Which action will demonstrate the need for further education by their preceptor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)

Correct Answer is ["A","B","C","E"]

Explanation

A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take?

Correct Answer is A

Explanation

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