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.
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Related Questions
Correct Answer is C
Explanation
A. Measuring weight and height is not an immediate priority in the management of shock.
B. Inserting an indwelling urinary catheter is not a priority in the early management of shock.
C. Initiating IV access is crucial for fluid resuscitation and medication administration in a child with shock.
D. While ECG monitoring is important, it is not as immediately necessary as establishing IV access for shock management.
Correct Answer is C
Explanation
A. Constipation is not typically associated with sickle cell crisis. While it can occur due to medications or dehydration, it is not a primary symptom of a crisis.
B. Bradycardia is not a typical manifestation of sickle cell crisis. The patient might experience tachycardia due to pain or dehydration.
C. Pain is the hallmark symptom of a sickle cell crisis. The sickle-shaped red blood cells obstruct blood flow, leading to ischemia and severe pain, often in the joints or abdomen.
D. Fever can occur if there is an infection, but pain is the most characteristic finding in a sickle cell crisis.
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