A nurse is assisting with the care of an infant who has myelomeningocele.
Which of the following actions should the nurse take?
Apply a sterile, moist dressing on the sac.
Monitor the infant's temperature rectally.
Encourage the guardian to cuddle with the infant.
Maintain the infant in a supine position.
The Correct Answer is A
Choice A rationale
Applying a sterile, moist dressing on the sac helps prevent infection and keeps the tissue moist, promoting healing.
Choice B rationale
Monitoring the infant's temperature rectally can increase the risk of infection and is not recommended.
Choice C rationale
Encouraging the guardian to cuddle with the infant is important for bonding but doesn't directly address the care of myelomeningocele.
Choice D rationale
Maintaining the infant in a supine position can put pressure on the sac, increasing the risk of rupture and infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D,C,A,B
No explanation
Correct Answer is B
Explanation
Choice A rationale
Learning to use creative energies is associated with the initiative vs. guilt stage, typically seen in preschool-aged children. During this stage, children assert control and power over their environment through directing play and other social interactions.
Choice B rationale
Defining a sense of self pertains to the identity vs. role confusion stage, which occurs in adolescence. This stage focuses on developing a personal identity and a sense of self. Adolescents explore different roles, beliefs, and values to form a unique identity.
Choice C rationale
Building a sense of trust is linked with the trust vs. mistrust stage, experienced in infancy. In this stage, infants learn to trust their caregivers and environment if their needs are consistently met, establishing a foundation for future relationships.
Choice D rationale
Learning to perform tasks independently corresponds to the autonomy vs. shame and doubt stage, typical of toddlers. In this stage, children develop a sense of personal control over physical skills and a sense of independence.
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