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 D
Explanation
Choice Areason: Decreased urine output is not directly related to ventriculoperitoneal shunt displacement. It may indicate other issues such as dehydration or kidney problems.
Choice Breason: Increased sleeping is not a specific indicator of shunt displacement. While it may be a concern if there are significant changes in the child's sleep patterns, it is not a definitive sign of this complication.Choice C reason: Hyperactive bowel sounds are not associated with shunt displacement. They may indicate gastrointestinal issues but are not relevant to the function of a ventriculoperitoneal shunt.
Choice D reason: An elevated temperature can be an indicator of shunt displacement, as it may suggest an infection or other complications related to the shunt. Parents should be aware of this sign and seek medical attention if it occurs.
Correct Answer is D
Explanation
Choice A reason:
This option addresses electrical safety, which is important for preventing shocks and strangulation hazards in toddlers. However, it does not directly prevent burn injuries from hot water, which is the focus of the question. While hiding wires reduces overall household risks, it does not mitigate scalding hazards. Therefore, this choice is not the correct answer in the context of hot water burn prevention.
Choice B reason:
Turning pot handles toward the back of the stove is a well-known safety measure to prevent toddlers from pulling down hot pots and pans. This reduces the risk of scalds and burns in the kitchen environment. However, the question specifically emphasizes hot water burns, which are more commonly caused by tap water and bathing accidents. Thus, while helpful, this measure does not directly address the hazard highlighted in the scenario.
Choice C reason:
Encouraging outdoor play outside peak sun hours is a measure aimed at reducing sunburn and heat exposure. Sunburn is technically a type of burn, but it is not related to hot water scalds. The question focuses on preventing injuries from household hot water sources, making this option less relevant. While beneficial for overall child safety, it does not answer the specific teaching point.
Choice D reason:
Setting the water heater to 49°C (120°F) is the most effective intervention to prevent scald injuries from hot water in toddlers. Toddlers are at high risk of burns during bathing or when exposed to hot tap water. Lowering the water heater temperature reduces the severity of burns if accidental exposure occurs. This measure directly addresses the hazard in the question, making it the correct answer.
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