A nurse is caring for a neonate who has a myelomeningocele and is admitted to the newborn intensive care unit (NICU) awaiting surgery. Which of the following nursing goals has the highest priority in the care of this infant?
Provide age-appropriate stimulation.
Educate the parents about the defect.
Promote maternal-infant bonding.
Maintain integrity of the sac.
The Correct Answer is D
A. While stimulation is important, the priority in this case is ensuring the infant’s safety and preventing further injury to the defect.
B. Education is vital but secondary to the immediate physical care needs of the infant.
C. Promoting bonding is important but does not take precedence over maintaining the integrity of the sac.
D. Maintaining the integrity of the sac is the highest priority to prevent infection and further neurological damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Tracheoesophageal fistula involves an abnormal connection between the esophagus and trachea, typically presenting with respiratory distress, coughing, and feeding difficulties, not a palpable abdominal mass and blood in stools.
B. Hypertrophic pyloric stenosis is characterized by projectile vomiting, dehydration, and an olive-shaped mass in the upper abdomen, not blood and mucus in the stools.
C. Inguinal hernia may present with a bulging mass in the groin area, but it does not cause blood or mucus in stools.
D. Intussusception is characterized by the telescoping of one part of the intestine into another, which can cause a palpable mass, abdominal pain, and stools mixed with blood and mucus (often referred to as "currant jelly" stools).
Correct Answer is A
Explanation
A. The child should sit upright with the head tilted forward to prevent blood from flowing down the throat, which could cause choking or aspiration. Applying pressure on the nostrils for 10 minutes is an effective method for stopping most nosebleeds.
B. While ice may help constrict blood vessels, it is not the primary intervention for a nosebleed. Holding pressure is more effective.
C. Tilting the head back can cause blood to flow into the throat and potentially lead to choking or vomiting.
D. Lying the child supine increases the risk of blood flowing into the throat and airway, making it unsafe.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.