A nurse is orienting a newly licensed nurse in the care of an infant who has myelomeningocele.
Which of the following actions by the new nurse indicates the teaching has been effective?
Takes an axillary temperature.
Places the infant in a side-lying position.
Maintains a dry dressing over the sac.
Performs range of motion on the infant's hips.
The Correct Answer is A
A. Infants with spina bifida, including those with myelomeningocele, have an increased risk of rectal anomalies, so avoiding rectal temperatures is essential. The correct and safe method of temperature measurement for these infants is typically axillary.
B. Placing the infant in a side-lying position is not recommended for a child with myelomeningocele. The preferred position is prone to avoid pressure on the sac and reduce the risk of rupture and infection.
C. Maintains a dry dressing over the sac: While the sac should be kept covered, it is typically kept moist with sterile saline-soaked gauze to prevent it from drying out and to minimize the risk of infection.
D. Performs range of motion on the infant's hips: Range of motion exercises might be indicated later on, but initially, the focus is on protecting the sac and preventing complications.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Nephrotic syndrome is a kidney disorder that causes your body to pass too much protein in your urine.
Swelling around the eyes is the most common sign of nephrotic syndrome in children 2.
Choice A is incorrect because smokey brown urine is not a symptom of nephrotic syndrome.
Choice C is incorrect because hypertension (high blood pressure) is a complication of nephrotic syndrome, not a symptom.
Choice D is incorrect because polyuria (frequent urination) is not a symptom of nephrotic syndrome.
Correct Answer is C
Explanation
Neural tube defects are birth defects of the brain, spine, or spinal cord that happen in the first month of pregnancy.
Spina bifida is a neural tube defect that affects the spine.
Choice A, Hydrocephalus, is not a neural tube defect but rather a condition where there is an accumulation of cerebrospinal fluid within the brain.
Choice B, Cerebral palsy, is not a neural tube defect but rather a group of disorders that affect movement and muscle tone or posture.
Choice D, Muscular dystrophy, is not a neural tube defect but rather a group of genetic diseases that cause progressive weakness and loss of muscle mass.
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