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 C
Explanation
Rationale:
A. Increasing the rate of infusion of IV oxytocin could exacerbate the uterine hyperstimulation and fetal decelerations, potentially leading to fetal distress. It is not appropriate in this situation.
B. Slowing the client's rate of breathing would not address the issue of fetal decelerations caused by uterine hyperstimulation. This action is not relevant to the situation described.
C. Discontinuing the infusion of the IV oxytocin is the correct action in this scenario. The presence of uniform decelerations beginning at the peak of contractions suggests uterine hyperstimulation, likely caused by oxytocin. Discontinuing the oxytocin infusion allows the uterus to rest, reducing the risk of further fetal distress.
D. Decreasing the rate of infusion of the maintenance IV solution is not the priority in this
situation. The issue is uterine hyperstimulation caused by oxytocin, so discontinuing the oxytocin infusion is the appropriate action to take.
Correct Answer is C
Explanation
Rationale:
A. While covering the cord with a sterile, moist saline dressing is important, it is not the first priority when the umbilical cord is prolapsed.
B. While preparing for an immediate birth may become necessary, the first action should be to relieve pressure on the cord to prevent cord compression and compromise to fetal circulation.
C. This is the priority action to prevent cord compression and maintain fetal oxygenation.
D. Placing the client in the knee-chest position can help relieve pressure on the cord, but the nurse's immediate action should be to manually support the cord while awaiting further
instructions from the healthcare provider.
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