A nurse is caring for a newborn who was born 6 hr ago.
Complete the diagram by dragging from the choices below to specify what condition the newborn is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the newborn's progress.
The Correct Answer is []
Potential condition
Correct Answer: B. Meningocele
Rationale: Based on the provided physical examination details, the newborn is most likely experiencing a meningocele, which is indicated by the presence of a sac in the lumbar area. This condition is a type of neural tube defect where a sac of fluid comes through an opening in the baby's back. However, the absence of other neurological symptoms and the intact reflexes suggest that the condition has not severely affected the newborn's neurological functions.
Actions to Take (2)
Correct Answers: C, E
The two actions the nurse should take to address this condition include: applying a non-adhering sterile saline moist compress to the sac to prevent it from drying and to protect it from trauma, and educating the guardians about the condition, its implications, and the potential need for surgical intervention to repair the defect.
Parameters to monitor
Correct Answer: A, C
Rationale: The two parameters the nurse should monitor to assess the newborn's progress are the head circumference and serial head ultrasounds. Monitoring head circumference is crucial as an increase may indicate hydrocephalus, which can be associated with meningocele. Serial head ultrasounds are necessary to assess for any changes in the brain structure or development of hydrocephalus. These measures will help ensure that any complications are identified and managed promptly.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Asking a psychiatrist to talk with the parents may not be the most appropriate immediate
action when abuse is suspected. Reporting to the authorities should take precedence to ensure the child's safety.
B. Obtaining a detailed history is important but should be done after reporting the suspected abuse to the authorities.
C. Separating the child from the parents may not be feasible or appropriate in all situations.
Reporting to the authorities is the priority action to ensure proper investigation and protection of the child.
D. Report the suspected abuse to the authorities. Suspected child abuse must be reported
immediately to the appropriate authorities, such as child protective services or law enforcement, for further investigation and intervention to ensure the safety and well-being of the child.
Correct Answer is A
Explanation
A. "I'll let my baby drain one breast at each feeding."
Rationale:
A. "I'll let my baby drain one breast at each feeding." This statement indicates understanding because allowing the baby to empty one breast at each feeding helps in relieving breast engorgement by effectively removing milk. It promotes better milk flow and prevents overproduction.
B. Feeding the baby every 2 hours is a common recommendation, but it may not specifically address breast engorgement management.
C. Cold compresses can help reduce discomfort from engorgement, but they should be applied after feeding, not before.
D. While herbal teas can sometimes provide relief for engorgement, this statement does not address the direct management of engorgement through breastfeeding techniques.
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