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
Acute lead poisoning in toddlers can cause anorexia, as well as vomiting, abdominal pain, and constipation.
These symptoms can progress to seizures, coma, and even death if not treated promptly.
Choice A, increased urinary output, is not the correct answer because lead poisoning can cause a decrease in urinary output due to the effect of lead on the kidneys.
Choice C, diarrhea, is not the correct answer because lead poisoning is more likely to cause constipation than diarrhea.
Choice D, jaundice, is not the correct answer because jaundice is not a common finding in lead poisoning.
Jaundice is a yellowing of the skin and whites of the eyes caused by an excess of bilirubin in the blood, which is not directly related to lead poisoning.
Correct Answer is D
Explanation
a.Talcum powder is not recommended for use with infants because it can be inhaled, potentially causing respiratory problems. Instead, a barrier cream or ointment (such as zinc oxide or petroleum jelly) should be used to protect the skin from moisture and irritants.
b.While cloth diapers can be less irritating than some disposable diapers, they may not be as effective at keeping the skin dry. The priority is to keep the area dry and clean, regardless of the type of diaper used. Super-absorbent disposable diapers are often recommended because they can help keep the skin dry.
c.Exposing the skin to hot air can cause burns and further irritation. Instead, allowing the skin to air dry naturally (without the use of hot air) during diaper changes can be beneficial.
d.A moisturizer creates a barrier between the skin and irritants like urine and stool.Wiping with a moisturizer can minimize friction during cleaning, which can be uncomfortable for the baby and further irritate the skin.Some moisturizers can help soothe and hydrate the inflamed skin, promoting healing.
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