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.
Nursing Test Bank
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 D
Explanation
This is the recommended technique for chest compressions on an infant, as it provides adequate blood flow without causing injury12.
Choice A.
Deliver compressions just above the nipple line is incorrect, as this is not the correct location for chest compressions on an infant.
The correct location is below the nipple line, at the center of the chest.
Choice B.
Deliver compressions with the heel of one hand is incorrect, as this is the technique for chest compressions on a child, not an infant. For an infant, two fingers are used instead of one hand13.
Choice C.
Deliver compressions at a depth of 5 cm (2 in) is incorrect, as this is too deep for an infant’s chest.
The correct depth for an infant is about 4 cm (1.5 in) or 1/3 the depth of the
chest12.
Therefore, choice D is the best answer.
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