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 C
Explanation
Choice A rationale
Allowing an additional 30 minutes of play before bedtime can lead to overstimulation and delay the child's ability to settle down for sleep. Consistent bedtime routines are crucial for establishing healthy sleep patterns in children.
Choice B rationale
Letting the child sleep in the parent's bed can create dependency and difficulty in establishing the child's own sleep routine and space. This practice can disrupt both the parent's and child's sleep in the long term.
Choice C rationale
Keeping a night light on provides a sense of security and comfort for a child who may be afraid of the dark. This helps the child feel safe and can ease the transition to bedtime.
Choice D rationale
Staying with the child until they fall asleep, especially if crying, can reinforce the behavior and make it harder for the child to develop self-soothing skills. It can lead to increased dependency on the parent's presence to fall asleep.
Correct Answer is D
Explanation
Choice A rationale
Introducing well-cooked table foods should begin around 8-10 months of age when the baby is ready for finger foods and has developed better chewing skills.
Choice B rationale
Starting solid foods at 3 months old is too early and can interfere with breastfeeding or formula feeding, increasing the risk of allergies and digestive issues.
Choice C rationale
Cow's milk should not be introduced until 12 months of age, as infants need the nutrients from breast milk or formula during their first year for optimal growth.
Choice D rationale
It is recommended to wait until the baby is at least 6 months old before introducing fruit juice, and even then, it should be given in limited quantities to avoid excessive sugar intake.
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