The nurse is caring for a newborn born at 30 weeks' gestation.
Which assessment finding should the nurse anticipate?

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.

Choice A rationale

A large bruise on the forehead of a 2-year-old could occur from accidental falls, which are common at this developmental stage due to increased mobility and decreased coordination. It does not necessarily suggest abuse unless accompanied by other suspicious findings.

Choice B rationale

Circular abrasions around the wrists are highly indicative of physical abuse as they suggest binding injuries. Restraining a child is neither acceptable nor normal, and such findings must be reported for further investigation by child protective services.

Choice C rationale

A burn on the palm of a 10-year-old’s hand raises concerns for abuse as accidental burns usually occur on accessible areas like arms or legs, not the palm. This pattern could indicate intentional infliction, requiring mandatory reporting to authorities.

Choice D rationale

Splash burns on the front torso in a 6-year-old are suspicious if inconsistent with the child’s developmental abilities or history provided by caregivers. Intentional scald burns often follow specific patterns, like splash marks, and must be reported for investigation.