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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Decreased blood pressure: Menopause can be associated with fluctuations in blood pressure, but it is not typically characterized by decreased blood pressure.
B. Urinary retention: Urinary symptoms such as urgency, frequency, or stress incontinence may occur during menopause, but urinary retention is not a typical manifestation.
C. Dryness with intercourse: Vaginal dryness is a common symptom of menopause due to decreased estrogen levels, leading to changes in vaginal tissue and lubrication, which can cause discomfort during intercourse.
D. Elevation in body temperature above 37.8°C (100°F): Hot flashes are a hallmark symptom of menopause and are characterized by sudden feelings of heat, sweating, and flushing, but they do not typically cause a sustained elevation in body temperature.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
Explanation
The nurse should anticipate a provider prescription for an antiviral medication, as evidenced by the client's presentation of small pinpoint open vesicles and pustules on the labia majora, which are indicative of a herpes simplex virus infection, a common cause of genital ulcers. The clear drainage and absence of pain are consistent with this diagnosis. Additionally, the thick, mucopurulent discharge could suggest a secondary bacterial infection, for which the provider may prescribe antibiotics.
Antiviral medication is likely prescribed for perineal lesions because these can be indicative of a viral infection, such as herpes. The nurse should recognize the need for antivirals to manage and treat the underlying cause.
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