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.
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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Related Questions
Correct Answer is C
Explanation
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.
Correct Answer is A
Explanation
Feeding the baby every 2 hours helps to ensure frequent emptying of the breasts, which can help alleviate engorgement by reducing milk stasis and promoting milk production regulation.
Applying cold compresses before feeding may temporarily reduce discomfort but does not address the underlying cause of engorgement or promote milk removal.
Drinking herbal tea is not proven to effectively reduce breast engorgement, and it is important for the client to focus on frequent breastfeeding or pumping to alleviate engorgement.
Allowing the baby to drain one breast at each feeding may lead to uneven milk production and exacerbate engorgement. It is important for the client to offer both breasts at each feeding to ensure adequate milk removal from both breasts.
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