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 B
Explanation
A. Applying suction for 20 seconds:
Suctioning for 20 seconds is within the recommended duration for endotracheal suctioning in children. It allows adequate time for removing secretions without causing excessive trauma to the airway.
B. Introducing the catheter without suction:
This action is incorrect. When performing endotracheal suctioning, the catheter should be introduced into the endotracheal tube while applying suction. Introducing the catheter without suction may not effectively remove secretions and can lead to ineffective suctioning.
C. Rotating the catheter between the thumb and forefinger while suctioning:
Rotating the catheter between the thumb and forefinger while suctioning helps to prevent the catheter from sticking to the airway walls and facilitates the removal of secretions. This action is appropriate and helps ensure effective suctioning.
D. Allowing the child to rest for 30 to 60 seconds between suctioning passes:
Allowing the child to rest between suctioning passes helps minimize hypoxia and discomfort during the procedure. This action is appropriate and ensures that the child has adequate time to recover before the next suctioning pass.
Correct Answer is B
Explanation
Infusion rate (mL/hour) = Total volume (mL) / Total time (hours)
Given:
Child's weight: 10 kg
Ordered volume: 40 mL/kg
Total time: 4 hours
First, calculate the total volume of Lactated Ringer's solution needed:
Total volume = 40 mL/kg × 10 kg = 400 mL
Then, divide the total volume by the total time to find the infusion rate:
Infusion rate = 400 mL / 4 hours = 100 mL/hour
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