A nurse is caring for a newborn who has a myelomeningocele and is admitted to the newborn intensive care unit (NICU) to await surgery. Which of the following nursing goals is priority in the care of this infant?
Promote maternal-infant bonding
Provide age-appropriate stimulation.
Educate the parents about the defect.
Maintain integrity of the sac.
The Correct Answer is D
A. Promote maternal-infant bonding: While promoting maternal-infant bonding is essential for the overall well-being of the newborn and family, it may not be the priority in this situation. The immediate focus is on medical management and preventing complications associated with the myelomeningocele.
B. Provide age-appropriate stimulation: Age-appropriate stimulation is important for newborn development, but in the case of a newborn with a myelomeningocele awaiting surgery, the priority is to minimize any potential risk of injury or infection to the exposed neural tissue.
C. Educate the parents about the defect: Education about the myelomeningocele and its long-term implications is crucial for the parents' understanding and ability to care for their child. However, while important, this may not be the priority at the immediate moment.
D. Maintain integrity of the sac: This is the priority nursing goal in caring for a newborn with a myelomeningocele awaiting surgery. The sac covering the exposed neural tissue must be carefully protected to prevent infection and further damage. Measures such as keeping the sac moist with sterile saline dressings and preventing trauma to the area are essential to maintain its integrity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Instruct the client to cough. Coughing is generally encouraged after chest physiotherapy to help expel loosened secretions, but it is not the first action. The bronchodilator should be administered first to maximize the effectiveness of the chest physiotherapy.
B. Perform vibration while the client exhales slowly through the nose. Vibration is a component of chest physiotherapy used to help loosen secretions during exhalation, but it is performed after the bronchodilator is administered and once the client is positioned properly.
C. Percuss the upper posterior chest.Percussion helps to mobilize secretions but is typically done after the bronchodilator has been administered to allow for more effective airway clearance.
D. Administer albuterol by nebulizer.Administering albuterol first dilates the airways, making it easier to mobilize and clear secretions during percussion, vibration, and postural drainage.
Correct Answer is C
Explanation
A. Coloring book with crayons:
Coloring activities with crayons are typically more suitable for older children who have developed fine motor skills and hand-eye coordination. At 10 months old, infants are still in the early stages of motor development and may not have the dexterity to hold and manipulate crayons effectively. Additionally, infants at this age are more likely to put objects in their mouths, which poses a choking hazard with crayons.
B. Large-piece puzzles:
Puzzles with large pieces can be beneficial for older children's cognitive development by promoting problem-solving skills and hand-eye coordination. However, at 10 months old, infants are still developing their motor skills and may not have the ability to manipulate puzzle pieces effectively. Puzzles with small pieces can also pose a choking hazard for infants.
C. Crib gym:
A crib gym is a suitable toy for a 10-month-old infant as it provides opportunities for visual stimulation, reaching, grasping, and hand-eye coordination development. Crib gyms typically consist of hanging toys or objects that the infant can bat at or grasp while lying in their crib or playpen. This type of toy encourages exploration and interaction while ensuring safety within the confines of the crib.
D. Put-in take-out toy:
Put-in take-out toys involve placing objects into a container and then removing them, which can be engaging for infants. However, while this type of toy may provide some entertainment for a 10-month-old, it may not offer as much visual and tactile stimulation as a crib gym. Additionally, some put-in take-out toys may have smaller parts that pose a choking hazard for infants, so careful supervision is necessary.
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