A nurse is caring for an infant who has spina bifida.
Which of the following actions should the nurse take?
Feed the infant through an NG tube.
Place the infant in a prone position.
Cover the infant’s lesion with a dry cloth.
Perform range-of-motion (ROM) exercises to the infant’s hips.
The Correct Answer is B
Choice A rationale
Feeding an infant with spina bifida through an NG tube may not be necessary unless the child has specific feeding difficulties or other health issues. Spina bifida does not typically affect a child’s ability to eat or swallow.
Choice B rationale
Placing an infant with spina bifida in a prone position can help protect and care for the lesion on their back. It can also help prevent pressure sores and promote comfort.
Choice C rationale
Covering the infant’s lesion with a dry cloth is not typically recommended. The lesion should be kept clean and moist to promote healing and prevent infection.
Choice D rationale
While physical therapy and exercises can be beneficial for children with spina bifida, performing range-of-motion exercises to the infant’s hips may not be necessary unless specifically recommended by a healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale
Asking the guardians to leave during the procedure is not recommended. The presence of a familiar person can provide comfort and reduce anxiety for the toddler during a stressful procedure.
Choice B rationale
Performing the procedure with the child in his bed can provide a sense of security and familiarity, which can help reduce anxiety and fear.
Choice C rationale
Using the child’s favorite toy to explain or distract during the procedure can help the child understand what to expect and provide a sense of control.
Choice D rationale
Applying lidocaine and prilocaine (EMLA) Cream to 2-3 potential insertion sites can help numb the area and reduce pain during the procedure.
Choice E rationale
Allowing the child to make one choice regarding the procedure can provide a sense of control and cooperation.
Correct Answer is A
Explanation
Choice A rationale:
Developmental dysplasia of the hip (DDH) is a condition in which the hip joint is not properly formed or is unstable. Asymmetric thigh folds are a common finding in infants with DDH, as the affected hip may be dislocated or subluxated, leading to a difference in thigh fold appearance.
Choice B rationale:
An inwardly turned foot is not a specific indication of DDH. Instead, it may suggest other conditions, such as clubfoot or metatarsus adductus (no reference).
Choice C rationale:
Absent plantar reflexes are not associated with DDH. This finding might indicate a neurological issue or spinal cord injury (no reference).
Choice D rationale:
A lengthened thigh is not a typical finding in DDH. Instead, a shortened thigh on the affected side might be present due to the displacement of the femoral head (no reference).
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