How it Works
Try Naxlex NCLEX-RN (Free-Trial)

An infant has just undergone surgical repair of a myelomeningocele.
What is the priority nursing intervention to perform immediately following the procedure?

A.

Position the infant supine to protect the surgical site.

B.

Monitor head circumference.

C.

Monitor intake and output.

D.

Maintain skin integrity.

Answer and Explanation

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.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"C"},"E":{"answers":"B"}}

Explanation

A. Formation of fingers, toes, and facial features

Correct Trimester: 1st Trimester (Conception – 13 weeks)
Explanation:
By the end of the 1st trimester, organogenesis (organ formation) is largely complete.

  • Weeks 7–8: Limb buds appear and begin differentiating into arms and legs.

  • Weeks 9–12: Fingers, toes, facial features (eyes, nose, lips, ears) become clearly defined.
    This is a critical period for congenital malformations if exposed to teratogens.

B. Fetus can hear and respond to external stimuli

Correct Trimester: 2nd Trimester (14–26 weeks)
Explanation:

  • Around 18–20 weeks: The fetus develops the ability to hear sounds.

  • External sounds can startle the fetus, and the heartbeat may change in response.

  • Mother's voice and music can be recognized at this stage.

C. Increase in body fat reserves

Correct Trimester: 3rd Trimester (27–40 weeks)
Explanation:

  • In the final trimester, especially after week 32, fat accumulates under the skin.

  • This provides energy and helps with temperature regulation after birth.

  • The fetus also gains the most weight during this period.

D. Brain develops most rapidly during this time

Correct Trimester: 3rd Trimester (27–40 weeks)
Explanation:

  • Although brain development starts early, the most rapid growth occurs in the third trimester.

  • There's a dramatic increase in brain volume, cortical folding, and neural connectivity.

  • This trimester is essential for cognitive and motor development.

E. Gender can be determined

Correct Trimester: 2nd Trimester (14–26 weeks)
Explanation:

  • By week 18–20, an ultrasound can reliably show external genitalia.

  • The sex organs begin forming in the 1st trimester, but become distinct and visible by the 2nd trimester.

  • This is when many parents find out the baby's gender via an anatomy scan.

Correct Answer is A

Explanation

Choice A rationale

Horizontal eustachian tubes in children with cleft palate increase the risk of otitis media due to impaired drainage and ventilation. Surgical closure of the palate helps restore anatomical structure, reducing the incidence of middle ear infections and associated complications.

Choice B rationale

Small external ear structure is not anatomically linked to hydrocephalus, and diuretics are unrelated to managing this condition. Hydrocephalus stems from cerebrospinal fluid accumulation, not external ear anatomy, making this option inaccurate.

Choice C rationale

A large tongue may lead to airway obstruction but is not linked to otitis externa. Ear drops manage external ear infections but do not address anatomical changes associated with cleft palate, which impacts the eustachian tubes and middle ear.

Choice D rationale

An opening in the lip does not directly cause pneumonia. Pneumonia is primarily a respiratory condition influenced by infections, not lip anatomy. Corticosteroids are not standard interventions for pneumonia related to cleft palate complications.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register