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 A
Explanation
Choice A rationale
Postpartum depression is more likely in individuals with a history of depression due to predisposing factors such as neurochemical imbalances and psychosocial stressors. Pregnancy and childbirth exacerbate these vulnerabilities through hormonal fluctuations, sleep deprivation, and new parenting stress. Early identification of at-risk populations is critical to prevent severe outcomes and promote maternal mental health.
Choice B rationale
Psychotic behavior is not a common feature of postpartum depression. It is more characteristic of postpartum psychosis, a rare and severe condition that requires immediate intervention. Postpartum depression primarily manifests as feelings of sadness, anxiety, and difficulty bonding with the infant, rather than psychotic symptoms like delusions or hallucinations.
Choice C rationale
Harming the infant is not the most common manifestation of postpartum depression. While intrusive thoughts may occur, the condition primarily presents with emotional symptoms such as hopelessness, guilt, and fatigue. Focused therapy can address these feelings and help prevent rare but severe outcomes involving harm.
Choice D rationale
Postpartum depression typically develops within 1–4 weeks after delivery, with symptoms often emerging gradually. The claim that it begins within 48 hours is inaccurate and more representative of the "baby blues," a transient and less severe condition. Accurate diagnosis involves monitoring symptom progression over time. .
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Accurate measurement of intake and output is crucial after atrial septal defect repair to detect potential fluid imbalances or kidney dysfunction. Monitoring ensures early intervention in cases of dehydration or fluid overload.
Choice B rationale
Providing uninterrupted rest promotes recovery by minimizing stress on the cardiovascular system and reducing metabolic demands post-surgery. Adequate rest also allows tissue healing and stabilizes vital parameters.
Choice C rationale
Maintaining a thermoneutral environment prevents temperature fluctuations, which could increase metabolic demand and stress the healing heart. Temperature regulation is particularly important in infants with compromised cardiac function.
Choice D rationale
Encouraging bonding supports emotional and psychological recovery for both the infant and parents. Physical closeness can improve the infant's developmental outcomes and reduce parental anxiety after surgery.
Choice E rationale
Using an incentive spirometer 10 times hourly is not appropriate for infants. Incentive spirometers are designed for cooperative patients, typically older children or adults, as they require active participation in deep-breathing exercises.
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