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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Placing the infant safety seat in the middle of the back seat away from the windows is the safest position, protecting the child from potential impact during accidents and from direct sunlight or objects coming through windows.
Choice B rationale
Following the child's weight and height is crucial for safely transitioning from an infant car seat to a booster seat. This ensures proper restraint and protection as the child grows.
Choice C rationale
Allowing a baby to watch the driver while in the back seat indicates a forward-facing position, which is unsafe for infants. Rear-facing positions provide the best protection for an infant's head, neck, and spine.
Choice D rationale
Using a previously owned car seat with intact instructions can ensure proper installation and use. However, checking the seat's history and condition is crucial to ensure it meets current safety standards.
Correct Answer is C
Explanation
Choice A rationale
Walks with one hand held typically occurs around 12 months as infants gain balance and coordination for upright movement.
Choice B rationale
Sits unsupported usually happens around 6 months when infants' core muscles are strong enough to hold their torso upright.
Choice C rationale
Turning pages in a book is a fine motor skill that develops around 12 months as hand-eye coordination improves.
Choice D rationale
Rolling from front to back typically occurs around 6 months as infants develop stronger neck and upper body muscles.
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