An infant has just undergone surgical repair of a myelomeningocele.
What is the priority nursing intervention to perform immediately following the procedure?
Position the infant supine to protect the surgical site.
Monitor head circumference.
Monitor intake and output.
Maintain skin integrity.
The Correct Answer is B
Choice A rationale
Positioning the infant supine increases pressure on the surgical site, potentially disrupting healing or increasing the risk of cerebrospinal fluid leakage. Supine positioning is contraindicated immediately after myelomeningocele repair as it can compromise the integrity of the repair.
Choice B rationale
Monitoring head circumference detects signs of hydrocephalus, a common complication after myelomeningocele repair due to cerebrospinal fluid dynamics. Enlarging head circumference can indicate increased intracranial pressure and require immediate intervention to prevent further neurological damage.
Choice C rationale
Intake and output monitoring provides essential hydration and renal function data post-surgery. While important, it is not the priority intervention immediately following surgery, as it does not directly address complications such as hydrocephalus or infection risk.
Choice D rationale
Maintaining skin integrity prevents infection and promotes healing but does not address potential neurological complications. While this intervention remains vital for recovery, it is secondary to detecting hydrocephalus or fluid imbalances post-surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Exercise is encouraged for cystic fibrosis patients as it improves respiratory function and overall physical health. Outdoor activities like swinging and running benefit the child by promoting lung clearance through increased breathing depth, which supports disease management and physical development.
Choice B rationale
Chest therapy and postural drainage improve mucus clearance and lung function in cystic fibrosis patients. Performing these interventions regularly ensures respiratory health by reducing mucus accumulation and preventing infections, promoting the child’s well-being.
Choice C rationale
High-protein, high-calorie diets are essential for cystic fibrosis patients due to increased metabolic demands. Supplementing the diet with high-calorie formula supports weight gain and compensates for malabsorption. These interventions are pivotal for growth and energy maintenance.
Choice D rationale
Pancreatic enzymes are crucial for digestion and nutrient absorption in cystic fibrosis patients, as pancreatic insufficiency leads to malabsorption. Even with good appetite and bowel movements, skipping enzyme supplementation results in nutrient deficiencies, growth delays, and gastrointestinal issues.
Correct Answer is A
Explanation
Choice A rationale
Weighing an infant's diaper for output is a task suitable for unlicensed assistive personnel (UAP) because it involves data collection rather than clinical judgment or critical thinking. The results can be recorded and reported to the nurse for further assessment and interpretation.
Choice B rationale
Assessing a post-operative dressing requires clinical judgment to identify signs of infection, dehiscence, or other complications. This task is within the scope of a licensed nurse and should not be delegated to UAP to ensure patient safety.
Choice C rationale
Calculating the Morse Fall Scale involves understanding and interpreting risk factors, which requires critical thinking and clinical judgment. It is inappropriate for delegation to UAP, as they are not trained to analyze or interpret clinical data.
Choice D rationale
Performing an assessment of a child's developmental milestones requires knowledge of growth and development patterns, as well as clinical judgment to interpret findings. This task is outside the scope of UAP and must be performed by a licensed nurse.
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