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 D
Explanation
A. Assess vital signs → Important but secondary to fetal assessment.
B. Establish IV access → Necessary but not the first action.
C. Perform a sterile vaginal exam → This is done after fetal heart tones are assessed, as frequent exams increase infection risk.
D. Obtain fetal heart rate → The priority is to assess fetal well-being after membrane rupture to ensure there is no umbilical cord prolapse or fetal distress.
Correct Answer is ["A","B","C","E"]
Explanation
A. Difficulty feeding → Infants with heart failure have poor feeding due to fatigue from increased cardiac workload.
B. Tachypnea → Increased respiratory rate occurs due to pulmonary congestion and compensatory mechanisms.
C. Wheezes or rales → Pulmonary congestion or fluid overload can cause adventitious lung sounds.
D. Incorrect → Children with heart failure are often more comfortable sitting upright rather than lying flat (orthopnea).
E. Edema in feet and legs → Right-sided heart failure leads to peripheral edema.
F. Incorrect → Decreased urine output is common due to reduced renal perfusion. Increased urine output would not be expected.
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