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 B
Explanation
Choice A rationale
Elevated AFP levels are not typically associated with Down syndrome. In fact, pregnancies with Down syndrome often show decreased levels of AFP in maternal serum screening. AFP is a protein produced by the fetal liver, and its levels vary depending on developmental abnormalities like neural tube defects, not chromosomal disorders like Down syndrome.
Choice B rationale
Elevated AFP levels in a pregnant patient indicate potential neural tube defects such as spina bifida. Spina bifida results from incomplete closure of the fetal neural tube during early pregnancy, leading to exposure of neural tissues. AFP leaks into the maternal serum through this defect, thus raising its concentration significantly, which serves as a marker.
Choice C rationale
AFP levels are generally low in cases of Down syndrome due to chromosomal anomalies. Trisomy 21 pregnancies display distinctive serum markers, including decreased AFP. Elevated AFP does not signify Down syndrome because the pathology involves a different spectrum of physiological abnormalities.
Choice D rationale
While spina bifida is indeed a condition associated with elevated AFP, this statement is less accurate due to the phrasing. AFP elevations serve as an indicator rather than definitive confirmation of spina bifida. Further diagnostic tests like ultrasonography or amniocentesis are needed to confirm the condition.
Correct Answer is D
Explanation
Choice A rationale
Frequent cervical assessments increase the risk of introducing pathogens into the reproductive tract, especially with premature rupture of membranes (PROM). Continuous assessments are unnecessary unless labor is progressing or there are indications of infection. PROM exposes the fetus to potential infections like chorioamnionitis, and invasive procedures should be minimized to reduce infection risk.
Choice B rationale
Preparing for delivery is not a priority intervention unless signs of labor or fetal distress occur. At 32 weeks, preterm delivery poses significant risks, including respiratory distress syndrome and intraventricular hemorrhage. The goal is to prolong pregnancy to improve neonatal outcomes while closely monitoring the client for complications. Immediate delivery is reserved for emergent situations.
Choice C rationale
Providing emotional support is essential but does not directly address the risk of infection associated with PROM. While psychological support is beneficial, it is secondary to interventions aimed at preventing infection, which is the primary concern. Emotional well-being should complement, not replace, medical interventions.
Choice D rationale
Administering parenteral antibiotics helps prevent infection in cases of PROM, particularly when membranes rupture prematurely and expose the fetus to pathogens. Early antibiotic treatment reduces the risk of ascending infections like chorioamnionitis and neonatal sepsis. This intervention is crucial to protect maternal and fetal health during prolonged PROM.
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