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 A
Explanation
Choice A rationale
It's normal for an 8-month-old child to exhibit separation anxiety when their parents leave. This stage of development typically begins around 6 to 8 months of age and can peak around 14 to 18 months. It is a sign that the child has developed a strong attachment to their parents and understands the concept of object permanence—that objects and people continue to exist even when they are not visible.
Choice B rationale
While rest is important for an infant, this statement does not address the underlying issue of separation anxiety. It implies that the child's crying is due to fatigue, which can be misleading to the parents.
Choice C rationale
An overstimulating environment can cause distress in infants, but in this case, the crying is more directly related to separation anxiety. It's essential to differentiate between the two causes so that parents can respond appropriately.
Choice D rationale
Notifying a provider is unnecessary for typical separation anxiety. This response could unnecessarily alarm the parents and does not educate them on the normalcy of this developmental phase.
Correct Answer is B
Explanation
Choice A rationale
Capillary refill less than 2 seconds is a normal finding and suggests adequate perfusion. It is not indicative of a priority concern in this context.
Choice B rationale
Tingling in the right foot can indicate nerve damage or compromised circulation, which is critical to address in a patient with a fracture. This symptom could suggest complications like compartment syndrome, requiring immediate medical attention.
Choice C rationale
Respiratory rate of 24/min is slightly elevated but not directly related to the fracture's immediate complications. It requires monitoring but is not the priority.
Choice D rationale
A 2+ right pedal pulse indicates a normal pulse and adequate circulation in the foot. While important, it does not represent an immediate concern in this context.
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