A nurse is providing discharge teaching to the guardian of an infant who had a large myelomeningocele repair in the lumbar area. Which of the following instructions should the nurse include?
Perform clean intermittent catheterization every 8 hours.
Use a rectal thermometer to stimulate the passage of stool twice per day.
Anticipate gradual loss of function in the lower extremities.
Check toys and pacifiers for the presence of latex.
The Correct Answer is D
Choice A reason: This is not the correct instruction to include in the discharge teaching. Perform clean intermittent catheterization every 8 hours is a possible intervention for infants who have neurogenic bladder dysfunction due to spinal cord injury or spina bifida. However, not all infants who have myelomeningocele repair require catheterization. The nurse should assess the infant’s bladder function and teach the guardian how to perform catheterization if needed.
Choice B reason: This is not the correct instruction to include in the discharge teaching. Use a rectal thermometer to stimulate the passage of stool twice per day is a possible intervention for infants who have neurogenic bowel dysfunction due to spinal cord injury or spina bifida. However, not all infants who have myelomeningocele repair require rectal stimulation. The nurse should assess the infant’s bowel function and teach the guardian how to manage constipation or fecal incontinence if needed.
Choice C reason: This is not the correct instruction to include in the discharge teaching. Anticipate gradual loss of function in the lower extremities is a possible outcome for infants who have myelomeningocele repair, depending on the location and severity of the defect. However, the nurse should not assume that the infant will lose function in the lower extremities. The nurse should monitor the infant’s motor and sensory development and provide appropriate interventions to promote mobility and prevent complications.
Choice D reason: This is the correct instruction to include in the discharge teaching. Check toys and pacifiers for the presence of latex is an important precaution for infants who have myelomeningocele repair, as they are at risk of developing latex allergy due to repeated exposure to latex products during surgery and medical procedures. The nurse should teach the guardian how to identify and avoid latex-containing items and how to recognize and treat signs of allergic reaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: For individuals who are lactose intolerant, it is important to find alternative sources of calcium. Non-dairy sources such as fortified plant-based milks, leafy greens, and calcium-fortified foods can provide the necessary calcium without causing discomfort.
Choice B reason: Flavored yogurt often contains added sugars and may still have lactose, which can cause symptoms in those who are lactose intolerant. It's better to choose lactose-free options or plant-based alternatives.
Choice C reason: Lactose intolerance means that the body cannot effectively digest lactose found in milk, regardless of whether it is plain or chocolate. Therefore, it is not advisable to consume any milk that contains lactose.
Choice D reason: Drinking milk on an empty stomach can actually worsen symptoms for someone who is lactose intolerant. It is better to avoid milk or choose lactose-free alternatives.
Correct Answer is C
Explanation
Choice A reason: Administering the varicella vaccine to a child with leukemia and a low neutrophil count is not recommended because live vaccines are contraindicated due to the child's compromised immune system.
Choice B reason: Increasing the child's intake of fresh fruit is not advisable in this case because fresh fruits may carry bacteria that can cause infection in a child with a low neutrophil count.
Choice C reason: Avoiding rectal temperature measurements is important to prevent potential injury and infection in a child with a low neutrophil count, as their immune system is weakened.
Choice D reason: Restricting bathing to every other day is not necessary unless the child's skin is extremely sensitive due to chemotherapy. Regular bathing helps maintain hygiene and comfort.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.