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. Methylprednisolone: Methylprednisolone is a corticosteroid used for long-term management and prevention of asthma exacerbations. It has anti-inflammatory effects and is not typically used for immediate relief during an acute asthma attack.
B. Albuterol: Albuterol is a short-acting beta-agonist bronchodilator, which is the first-line medication for relieving acute bronchoconstriction during an asthma attack. It works quickly to open the airways and improve breathing.
C. Fluticasone: Fluticasone is an inhaled corticosteroid used for long-term asthma control and prevention of symptoms. It has anti-inflammatory effects but is not used for immediate relief during an acute asthma attack.
D. Beclomethasone: Beclomethasone is also an inhaled corticosteroid used for long-term asthma control and prevention of symptoms. Like fluticasone, it is not used for immediate relief during an acute asthma attack.
Correct Answer is C
Explanation
Correct answer: C
After a cleft‑palate repair, protecting the fresh suture line is paramount. Elbow restraintsare routinely used for the first 7–10 days postoperatively to prevent the toddler from putting fingers or objects into the mouth and disrupting the repair.
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