A nurse is orienting a newly licensed nurse in caring for an infant with myelomeningocele. Which of the following actions by the new nurse indicates the teaching has been effective?
Takes an axillary temperature.
Performs range of motion on the infant's hips.
Places the infant in a side-lying position.
Maintains a dry dressing over the sac.
The Correct Answer is D
Choice A reason: Taking an axillary temperature is standard but not specific to myelomeningocele care. While monitoring for infection is important, it does not address the unique need to protect the exposed spinal sac, which is critical to prevent infection and trauma in this condition.
Choice B reason: Performing range of motion on the hips risks damaging the myelomeningocele sac, which contains nerve roots. Movement could cause sac rupture or neurological worsening, as the exposed neural tissue is highly vulnerable, making this action contraindicated in this fragile condition.
Choice C reason: Side-lying positioning may be used but is not the most critical action. It helps avoid pressure on the sac, but maintaining a dry, sterile dressing is paramount to prevent infection, a life-threatening complication in myelomeningocele due to exposed neural tissue.
Choice D reason: Maintaining a dry dressing over the myelomeningocele sac prevents infection and trauma to exposed neural tissue. A sterile, moist environment protects the sac until surgical repair, reducing the risk of meningitis or further neurological damage, indicating effective understanding of this condition’s care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Woolen clothes can irritate eczema-prone skin, exacerbating inflammation and itching due to their rough texture. Eczema involves a defective skin barrier, and irritants like wool trigger flares, increasing discomfort and risking secondary infections from scratching, making this advice harmful.
Choice B reason: Fabric softeners contain fragrances and chemicals that can irritate eczema, worsening skin inflammation. Eczema requires hypoallergenic, fragrance-free detergents to minimize skin reactions, as the compromised skin barrier is highly sensitive to chemical irritants, leading to increased itching and flares.
Choice C reason: Topical corticosteroids reduce inflammation, redness, and itching in eczema by suppressing immune-mediated skin reactions. They restore the skin barrier, prevent flares, and reduce the risk of infection from scratching. Proper application under medical guidance is a cornerstone of eczema management in children.
Choice D reason: Bubble baths, with soaps and fragrances, strip natural oils from eczema-prone skin, worsening dryness and irritation. Daily baths should use gentle, fragrance-free cleansers to maintain skin hydration, as irritants exacerbate the defective skin barrier, leading to increased inflammation and discomfort.
Correct Answer is D
Explanation
Choice A reason: Droplet precautions are unnecessary for impetigo, a bacterial skin infection spread by direct contact, not respiratory droplets. Home isolation focuses on contact precautions, like avoiding shared items, to prevent spread, making droplet precautions irrelevant for managing impetigo transmission.
Choice B reason: Immunization is not available for impetigo, caused by Staphylococcus or Streptococcus bacteria. Unlike viral diseases, impetigo is treated with antibiotics, not prevented by vaccines. Household contacts require hygiene measures, not immunization, to avoid bacterial spread through direct contact.
Choice C reason: Chlorine baths are not a standard treatment for impetigo. While antiseptic washes may reduce bacterial load, chlorine can irritate skin, worsening lesions. Antibiotic therapy, topical or oral, is the primary treatment to eradicate the bacterial infection causing impetigo.
Choice D reason: Washing clothing in hot water kills bacteria causing impetigo, like Staphylococcus aureus, preventing reinfection or spread to others. Hot water and detergent effectively decontaminate fabrics, reducing bacterial load on items in contact with lesions, a critical measure for infection control.
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