A nurse is caring for an infant who has spina bifida. Which of the following actions should the nurse take?

Place the infant in prone position.

Cover the infant's lesion with a dry cloth.

Feed the infant through an NG tube.

Diapering over a low defect will keep the infant free from infection

Answer and Explanation

The Correct Answer is D

A. Place the infant in prone position.

This option is incorrect. Placing the infant in the prone position (lying on the stomach) could put pressure on the spinal lesion, potentially causing discomfort or complications. It's important to minimize pressure on the affected area in infants with spina bifida.

B. Cover the infant's lesion with a dry cloth.

This option is incorrect. While keeping the lesion clean and dry is important for preventing infection, simply covering it with a dry cloth may not provide adequate protection. Proper wound care techniques, such as using sterile dressings and cleaning the area with prescribed solutions, are typically necessary to prevent infection and promote healing.

C. Feed the infant through an NG tube.

This option is incorrect. While infants with severe forms of spina bifida may have difficulty feeding due to associated complications, such as difficulty swallowing or weak sucking reflexes, feeding through a nasogastric (NG) tube is not a standard intervention for spina bifida itself. Feeding methods would depend on the specific needs and abilities of the infant, and may involve breastfeeding, bottle-feeding, or other methods under the guidance of healthcare professionals.

D. Diapering over a low defect will keep the infant free from infection.

This option is correct. Diapering over a low defect (the opening in the spine caused by spina bifida) helps to keep the area clean and reduce the risk of infection. By properly covering the defect with a diaper, exposure to urine and feces, which can increase the risk of infection, is minimized. Additionally, regular diaper changes and proper hygiene practices are essential for preventing complications in infants with spina bifida.

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Correct Answer is C

Explanation

A. Obtain a throat culture.

This option is not appropriate as a primary nursing action in the acute management of epiglottitis. While obtaining a throat culture may be necessary for diagnostic purposes, it is not a priority in the immediate care of a child with suspected epiglottitis. The focus should be on ensuring airway patency and providing emergency treatment.

B. Visualize the epiglottis using a tongue depressor.

This option is contraindicated in the acute management of epiglottitis. Direct visualization of the epiglottis using a tongue depressor or other instruments can provoke spasm of the epiglottis and worsen airway obstruction. Attempting to visualize the epiglottis should be avoided until the child's airway has been secured in a controlled environment, such as in the operating room under anesthesia.

C. Provide moist air to reduce the inflammation of the epiglottis.

This option is appropriate. Providing moist air, such as humidified oxygen or a cool mist, can help soothe the inflamed tissues of the epiglottis and upper airway. Moist air may help alleviate discomfort and reduce inflammation, although it will not directly address the risk of airway obstruction. It is often used as supportive therapy in conjunction with other interventions.

D. Initiate airborne precautions.

This option is not necessary for the care of a child with epiglottitis. Epiglottitis is not typically transmitted through airborne droplets. The priority in the management of epiglottitis is ensuring a patent airway and providing appropriate treatment to reduce inflammation and prevent complications.

A. Applying suction for 20 seconds B. Introducing the catheter without suction C. Rotating the catheter between the thumb and forefinger while suctioning D. Allowing the child to rest for 30 to 60 seconds between suctioning passes

Correct Answer is B

Explanation

A. Applying suction for 20 seconds:

Suctioning for 20 seconds is within the recommended duration for endotracheal suctioning in children. It allows adequate time for removing secretions without causing excessive trauma to the airway.

B. Introducing the catheter without suction:

This action is incorrect. When performing endotracheal suctioning, the catheter should be introduced into the endotracheal tube while applying suction. Introducing the catheter without suction may not effectively remove secretions and can lead to ineffective suctioning.

C. Rotating the catheter between the thumb and forefinger while suctioning:

Rotating the catheter between the thumb and forefinger while suctioning helps to prevent the catheter from sticking to the airway walls and facilitates the removal of secretions. This action is appropriate and helps ensure effective suctioning.

D. Allowing the child to rest for 30 to 60 seconds between suctioning passes:

Allowing the child to rest between suctioning passes helps minimize hypoxia and discomfort during the procedure. This action is appropriate and ensures that the child has adequate time to recover before the next suctioning pass.

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A nurse is caring for an infant who has spina bifida. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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