A nurse is planning care for a newborn who has spinal bifida.
Which of the following actions should be included in the plan of care?
Obtain rectal temperatures
Cover the lesion with a dry dressing
Apply snug clean diapers
Place the newborn in the prone position .
The Correct Answer is D
Choice A rationale
Obtaining rectal temperatures is not recommended for newborns with spinal bifida. This is because the rectal route can introduce bacteria into the body, which can lead to infection.
Additionally, the rectal route may not provide an accurate temperature reading for these newborns.
Choice B rationale
Covering the lesion with a dry dressing is not recommended for newborns with spinal bifida. The lesion should be kept moist to prevent drying and cracking, which can lead to infection.
Choice C rationale
Applying snug clean diapers is not recommended for newborns with spinal bifida. This is because the pressure from the diaper can damage the exposed nerves and tissues in the lesion area.
Choice D rationale
Placing the newborn in the prone position is recommended for newborns with spinal bifida. This position helps to minimize pressure on the lesion and reduces the risk of trauma and infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
This statement is correct. It is recommended that newborns be breastfed 8 to 12 times per day, which is about every 2 to 3 hours.
Choice B rationale
Supplementing with formula after breastfeeding is not typically recommended unless there is a medical reason. Supplementing can interfere with the supply and demand process that increases milk supply.
Choice C rationale
Using plastic-lined breast pads can trap moisture and exacerbate sore nipples. It is recommended to use 100% cotton breast pads and to change them frequently to keep the nipples dry.
Choice D rationale
While staying hydrated is important for overall health, there is no definitive evidence that drinking more water will increase milk supply. However, some mothers find that staying well- hydrated helps with their overall comfort and well-being during breastfeeding.
Correct Answer is D
Explanation
Choice A rationale
Covering the cord with the diaper can create a moist environment that promotes bacterial growth and delays healing.
Choice B rationale
Washing the cord daily with mild soap and water is not recommended. It’s better to keep the cord dry and clean.
Choice C rationale
Applying petroleum jelly to the cord stump is not advised. It can create a moist environment that can delay the drying and falling off of the stump.
Choice D rationale
Giving a sponge bath until the cord stump falls off is the correct instruction. This prevents the stump from getting wet, which can delay healing and increase the risk of infection.
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