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. Preterm delivery: While preterm delivery can result in low birth weight, it is not typically considered a direct cause of being small for gestational age (SGA). SGA infants are generally small because of intrauterine growth restriction rather than preterm birth.
B. Fetal hyperinsulinemia: Fetal hyperinsulinemia may lead to macrosomia (large for gestational age) rather than SG
A.
C. Perinatal asphyxia: Perinatal asphyxia refers to oxygen deprivation around the time of birth and is not typically associated with SG
A.
D. Placental insufficiency: Placental insufficiency, resulting in poor nutrient and oxygen transfer to the fetus, is a common cause of SG
A. Insufficient placental function can limit fetal growth,
leading to a newborn being small for their gestational age.
Correct Answer is D
Explanation
A. Ibuprofen is not recommended for infants younger than 6 months due to the risk of adverse effects, including kidney impairment.
B. Positioning the infant on the abdomen can place pressure on the surgical site and increase the risk of disrupting the incision. Infants should be positioned on the back or side after cleft lip repair.
C. Offering a pacifier is avoided after cleft lip surgery because sucking can place stress on the incision and interfere with healing.
D. Encouraging the parents to rock the infant is appropriate. Gentle comforting measures help soothe the infant without putting pressure on the surgical site and support bonding and emotional comfort.
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