A newborn is diagnosed with a myelomeningocele. Which of the following is the priority nursing intervention immediately after birth?
Administer a high-protein diet to promote healing
Cover the sac with a sterile, moist dressing and position the infant prone
Place the infant in a supine position and monitor vital signs
Begin oral feeding immediately to promote nutrition
The Correct Answer is B
A. Administering a high-protein diet is incorrect because oral or enteral feeding is not the immediate priority after birth in an infant with myelomeningocele. The initial focus is on protecting the exposed neural tissue and preventing infection, not nutritional supplementation.
B. Covering the sac with a sterile, moist dressing and positioning the infant prone is correct because a myelomeningocele involves exposed spinal cord and meninges, placing the infant at high risk for infection and trauma. A sterile, nonadherent, moist dressing (often saline-soaked) prevents drying and rupture of the sac, while the prone position minimizes pressure on the defect until surgical repair can be performed.
C. Placing the infant in a supine position is incorrect because this position increases pressure on the spinal defect, raising the risk of rupture and infection. While monitoring vital signs is important, positioning must prioritize protection of the lesion.
D. Beginning oral feeding immediately is incorrect because feeding is not the immediate concern and may be delayed until the infant is stabilized and evaluated. Additionally, the risk of aspiration and the need for surgical intervention take precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Coarctation of the Aorta is incorrect because this defect causes obstruction of blood flow from the left ventricle to the aorta. It is a pressure load problem (left ventricular hypertension) rather than a left-to-right shunt, and it does not primarily increase pulmonary blood flow.
B. Tetralogy of Fallot is incorrect because this is a cyanotic defect characterized by right-to-left shunting due to pulmonary stenosis and a VSD. Pulmonary blood flow is often decreased rather than increased.
C. Transposition of the Great Arteries is incorrect because this is a cyanotic defect in which the aorta arises from the right ventricle and the pulmonary artery from the left ventricle, resulting in parallel circulation. Pulmonary blood flow is not increased by a left-to-right shunt.
D. Ventricular Septal Defect (VSD) is correct because it is a acyanotic defect that allows blood to flow from the left ventricle (higher pressure) to the right ventricle (lower pressure). This left-to-right shunt increases pulmonary blood flow, which can lead to symptoms such as tachypnea, poor weight gain, and frequent respiratory infections. VSDs are the most common congenital heart defect in infants.
Correct Answer is ["0.96"]
Explanation
Step 1: Divide the ordered dose by the available dose
400 ÷ 500 = 0.8
Step 2: Multiply by the available volume
0.8 × 1.2 = 0.96
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