A nurse is planning care for a newborn who has spina bifida. Which of the following actions should be included in the plan of care?

Apply snug, clean diapers.

Obtain rectal temperatures.

Place the newborn in the prone position.

Cover the lesion with a dry dressing.

Answer and Explanation

The Correct Answer is C

A. Applying snug diapers is not recommended as it can put pressure on the sacral lesion, potentially causing damage or infection.
B. Obtaining rectal temperatures is contraindicated due to the risk of bowel and nerve damage.
C. Placing the newborn in the prone position is the correct action, as it prevents pressure on the lesion and reduces the risk of trauma or infection.
D. Covering the lesion with a dry dressing is incorrect. The lesion should be covered with a moist, sterile, non-adherent dressing to prevent drying out and minimize infection risk.

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Correct Answer is A

Explanation

A. The fundus palpable to the right of midline suggests that the bladder is distended and pushing the uterus to the right, displacing it from its expected midline position.
B. Less than 2.5 cm of rubra lochia on the perineal pad is a normal amount of lochia for 2 hours postpartum and does not necessarily indicate bladder distention.
C. Client report of frequent uterine contractions may indicate uterine involution but does not directly assess bladder distention.
D. Client report of increased thirst may indicate dehydration but does not directly assess bladder distention.

A. Prepare for an exchange blood transfusion. B. Initiate early feeding. C. Suction excess mucus with a bulb syringe. D. Begin phototherapy.

Correct Answer is B

Explanation

A. Initiating early feeding helps promote the passage of meconium, which contains bilirubin, out of the newborn's body, reducing the risk of jaundice.

B. Preparing for an exchange blood transfusion is not appropriate for preventing jaundice at this stage. Exchange transfusion is a treatment option for severe hyperbilirubinemia that has not
responded to other measures.
C. Suctioning excess mucus with a bulb syringe is important for maintaining a patent airway in the newborn but does not directly prevent jaundice.
D. Beginning phototherapy is a treatment for jaundice once it has occurred but is not a preventive measure.

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A nurse is planning care for a newborn who has spina bifida. Which of the following actions should be included in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 2 hours postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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