A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states h abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort?

Answer: D. Maintains a dry dressing over the sac

A. Places the infant in a side-lying position.
Placing the infant in a side-lying position is not the most appropriate action for a child with myelomeningocele. It is often recommended to position infants in a supine (on their back) or prone (on their stomach) position to prevent pressure on the sac and facilitate optimal positioning for spinal alignment and care.

B. Takes an axillary temperature.
While taking an axillary temperature is a common practice for infants, it is not specific to the care of an infant with myelomeningocele. In fact, rectal temperatures are often preferred in clinical settings for more accurate readings in infants, particularly if there are concerns about infection or significant illness.

C. Performs range of motion on the infant's hips.
Performing range of motion exercises on the infant's hips may be appropriate for some infants but should be done cautiously in those with myelomeningocele. Depending on the extent of nerve damage, the infant may have limited mobility or lack sensation in the lower extremities, and inappropriate exercises could risk injury or further complications.

D. Maintains a dry dressing over the sac.
Maintaining a dry dressing over the sac is a critical action in the care of an infant with myelomeningocele. This condition involves a defect in the spinal column where the spinal cord and surrounding nerves protrude through the back, making the area susceptible to infection and injury. Keeping the dressing dry and intact protects the sac and prevents infection, indicating that the newly licensed nurse understands the importance of this essential nursing intervention.

Answer: (B) "I will apply heat."

Rationale:

A) "I will elevate the affected part." Elevating the affected part is an appropriate action for controlling a minor bleeding episode. Elevation helps reduce blood flow to the area, minimizing swelling and bleeding.

B) "I will apply heat." Applying heat is not recommended for managing bleeding episodes in hemophilia. Heat can increase blood flow to the affected area, which may worsen bleeding. Instead, applying ice or a cold compress is preferred as it helps constrict blood vessels and reduce bleeding and swelling.

C) "I will compress the site." Applying compression to the site is a correct method for controlling bleeding. Gentle pressure helps reduce blood flow and promotes clot formation, which is crucial in managing bleeding episodes.

D) "I will have my child rest." Encouraging rest is beneficial for a child with hemophilia during a bleeding episode. Resting helps minimize movement and further injury, which can assist in controlling bleeding and promoting recovery.