An infant has just undergone surgical repair of a myelomeningocele. What is the priority nursing intervention to perform immediately following the procedure?
Maintain skin integrity
Position the infant supine to protect the surgical site.
Monitor intake and output
Monitor head circumference
The Correct Answer is D
A. Maintain skin integrity → Important but not the priority immediately post-op.
B. Position the infant supine → Incorrect; the infant should be positioned prone (on the abdomen) to prevent pressure on the surgical site.
C. Monitor intake and output → Necessary but not the most urgent concern compared to hydrocephalus risk.
D. Monitor head circumference → Infants with myelomeningocele are at high risk for hydrocephalus due to cerebrospinal fluid obstruction. Increased head circumference may indicate increased intracranial pressure (ICP).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E","F"]
Explanation
A. A well-lit nursery is not recommended; a dim, quiet environment is preferred to reduce stimulation.
B. Feeding half-strength formula is not a standard intervention for infants experiencing withdrawal; feeding should follow the infant's needs and standard nutritional guidelines.
C. Swaddle newborn with legs flexed – Proper swaddling helps comfort the infant and can reduce withdrawal symptoms.
D. Maintain low stimulation environment – Minimizing noise and bright lights helps decrease overstimulation and agitation common in neonatal abstinence syndrome.
E. Offer the newborn a pacifier – A pacifier can be soothing and help manage irritability.
F. Administer oral glucose for comfort – Oral glucose (or sucrose) is a nonpharmacological intervention that can help alleviate pain and provide comfort.
Correct Answer is B
Explanation
A. Thyroid-stimulating hormone (TSH) → Thyroid disorders can cause menstrual irregularities but are not directly linked to PCOS.
B. Glucose → Insulin resistance is a hallmark of PCOS, making glucose monitoring essential for detecting diabetes risk.
C. BUN (Blood Urea Nitrogen) → PCOS does not primarily affect kidney function.
D. Liver function tests → While metabolic syndrome in PCOS can contribute to fatty liver, routine liver function tests are not a first-line concern.
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