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
Determining the time of the last pad change assesses the rate of bleeding, which is crucial for evaluating postpartum hemorrhage. Bright red blood saturation indicates active bleeding, requiring quantification. If pads are saturated within an hour, immediate intervention is needed to prevent hypovolemic shock.
Choice B rationale
Asking about clots identifies uterine atony or retained placental fragments. However, it does not prioritize the bleeding rate assessment, which is critical for immediate hemodynamic stability and guides urgency in management.
Choice C rationale
Cramping indicates uterine contractions aiding involution. While helpful for understanding uterine activity, it does not directly evaluate the severity or rate of blood loss, which poses an immediate risk to the client’s life.
Choice D rationale
Checking for the need to urinate helps assess bladder distension. A full bladder inhibits uterine contraction, worsening atony-related bleeding. Still, this line of questioning is less critical compared to assessing the bleeding's rate and volume.
Correct Answer is D
Explanation
Choice A rationale
The presence of Rh factor in the mother's blood and absence in the newborn’s does not lead to antibody formation targeting fetal red blood cells directly. Rh incompatibility arises when the mother lacks the Rh factor and forms anti-Rh antibodies against the Rh-positive fetal blood. This leads to hemolysis and hyperbilirubinemia in affected newborns.
Choice B rationale
Anti-A and anti-B antibodies are associated with ABO incompatibility, not Rh incompatibility. ABO incompatibility can cause mild hemolysis but does not lead to severe hyperbilirubinemia seen in Rh incompatibility. Rh incompatibility specifically involves anti-Rh antibodies produced by Rh-negative mothers targeting Rh-positive fetal red cells.
Choice C rationale
Receiving a transfusion with Rh-negative blood would not trigger Rh incompatibility. Rh incompatibility is driven by maternal sensitization to Rh-positive fetal blood during pregnancy or delivery, leading to antibody formation and subsequent hemolysis in future Rh-positive pregnancies.
Choice D rationale
When the mother lacks the Rh factor (Rh-negative), she can produce anti-Rh antibodies upon exposure to Rh-positive fetal blood. These antibodies cross the placenta and attack fetal red blood cells, causing hemolysis and hyperbilirubinemia. This process is the hallmark of Rh incompatibility-related pathology.
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