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 D

Explanation

A. Administering thyroid hormone replacement is not indicated for phenylketonuria (PKU). PKU is a metabolic disorder involving the inability to metabolize phenylalanine, an amino acid, and it does not involve thyroid dysfunction.
B. Blood glucose monitoring is not directly related to the management of PKU. In PKU, the focus is on monitoring and restricting phenylalanine intake, not blood glucose levels.
C. Obtaining a blood sample for blood type may be necessary for general newborn screening but is not specific to the management of PKU.
D. Initiating a controlled low-protein diet is the cornerstone of management for PKU. This diet restricts phenylalanine intake, which is essential for preventing neurological damage and
developmental delays in affected infants.

A. Ventrogluteal B. Vastus lateralis C. Dorso-gluteal D. Deltoid

Correct Answer is B

Explanation

A. The ventrogluteal site can be used for IM injections in older infants but is not typically used in newborns.
B. The vastus lateralis muscle is the preferred site for IM injections in newborns due to its size and accessibility.
C. The dorso-gluteal site is not recommended for IM injections in infants due to the risk of injury to the sciatic nerve.
D. The deltoid muscle is not typically used for IM injections in newborns due to its small size and less developed musculature.

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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 planning care for a newborn who has a new diagnosis of phenylketonuria (PKU). Which of the following actions should be included in the plan of care?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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