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.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale
It’s not uncommon for infants to eat the same foods prepared for the rest of the family, especially if these foods are healthy and properly prepared. However, it’s important to note that certain foods may pose a choking hazard or may not be suitable for an infant’s digestive system. For example, honey should not be given to children under 1 year of age due to the risk of botulism.
Choice B rationale
The American Academy of Pediatrics recommends that infants under 12 months of age should not drink cow’s milk. Cow’s milk lacks the necessary nutrients that infants need for growth and development. It also contains high concentrations of protein and minerals, which can stress an infant’s kidneys and cause other health problems.
Choice C rationale
Drinking from a cup with a cover, also known as a sippy cup, is a normal part of an infant’s development. It helps the child transition from a bottle to a regular cup. However, it’s important to monitor the child’s use of a sippy cup as prolonged use can lead to tooth decay.
Choice D rationale
Giving an infant finger foods like apple slices is a good way to encourage self-feeding and develop fine motor skills. However, the food should be cut into small, manageable pieces to prevent choking.
Correct Answer is C
Explanation
Choice A rationale
While providing age-appropriate stimulation is important for a newborn’s development, it is not the priority nursing goal for a newborn with a myelomeningocele. The immediate focus should be on preventing infection and injury to the exposed neural tissue.
Choice B rationale
Promoting maternal-infant bonding is important, but it is not the priority nursing goal for a newborn with a myelomeningocele. The immediate focus should be on preventing infection and injury to the exposed neural tissue.
Choice C rationale
Maintaining the integrity of the sac is the priority nursing goal for a newborn with a myelomeningocele. The sac contains exposed neural tissue that is at risk for injury and infection. Protecting the sac from damage and keeping it clean and moist until surgery can help prevent complications.
Choice D rationale
While educating the parents about the defect is an important part of nursing care, it is not the priority nursing goal for a newborn with a myelomeningocele. The immediate focus should be on preventing infection and injury to the exposed neural tissue.
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