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 A
Explanation
A. Bananas are a safe food choice for a 2-year-old, as they are soft and easy to chew, reducing the risk of choking.
B. Grapes should be cut into smaller pieces to prevent choking, as they are a common choking hazard for young children.
C. Celery can be difficult for a toddler to chew and may pose a choking risk, especially if not cut properly.
D. Raw carrots are hard and may pose a choking risk, especially if not cut into small, manageable pieces.
Correct Answer is D
Explanation
A. A WBC of 6,000/mm³ is within the normal range (4,500-11,000/mm³), and a postoperative infection is more likely to result in an elevated WBC count.
B. Purulent nasogastric drainage is more suggestive of a gastrointestinal issue unrelated to a perforated appendix and is not a common finding post-surgery.
C. Passage of dark red stool with mucus could suggest gastrointestinal bleeding or infection, but it is not typical postoperatively after a perforated appendix.
D. After surgery for a perforated appendix, peristalsis may be absent initially due to the effects of anesthesia, bowel manipulation, or inflammation from the infection. This is a normal postoperative finding.
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