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
The hepatitis B vaccine is recommended for all newborns within 24 hours of birth to provide early protection against the hepatitis B virus.
Choice B rationale
The PCV (Pneumococcal Conjugate Vaccine) is administered as a series of four doses, typically at 2, 4, 6, and 12-15 months of age.
Choice C rationale
The first dose of the DTaP (Diphtheria, Tetanus, and Pertussis) vaccine is typically given at 2 months of age, not during the initial well-baby visit after birth.
Choice D rationale
The MMR (Measles, Mumps, and Rubella) vaccine is recommended at 12-15 months of age and again at 4-6 years, not at 6 months. .
Correct Answer is C
Explanation
Choice A rationale
The infant's birth weight typically doubles by 4-6 months and triples by 1 year of age. If an infant's weight has tripled at 6 months, it may indicate overnutrition or an underlying health condition.
Choice B rationale
Lateral incisors usually appear between 9 to 13 months. At 6 months, the central incisors are more likely to be emerging.
Choice C rationale
The posterior fontanel typically closes by 2 to 3 months of age. Therefore, by 6 months, it is expected to be closed.
Choice D rationale
Infants usually sit without support around 8 months. At 6 months, they may sit with support or briefly without support but not consistently.
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