The nurse is in a maternal/child unit and is caring for a new parent.
The new parent expresses concern about their safety in the home.
The nurse provides the client with an intimate partner violence crisis center number.
Which of the following is a way the nurse can evaluate the client's response to the safety plan?

Choice A rationale

Elevating the head reduces the risk of aspiration by preventing stomach contents, including gastric juices, from entering the lungs. This position is essential for infants with tracheoesophageal fistula due to the abnormal connection between the trachea and esophagus, which increases aspiration risk.

Choice B rationale

Facilitating food digestion is not the primary goal of this positioning. Gastric motility and digestion are unaffected by head elevation, making this rationale irrelevant to the question. Therefore, this is not the correct choice.

Choice C rationale

While head elevation can improve breathing by reducing diaphragm compression, the primary purpose in this context is to prevent aspiration. Lung expansion is a secondary benefit, but it is not the main reason for this position.

Choice D rationale

Reducing stomach pressure is not the key reason for elevating the head in this case. Although head elevation can minimize intra-abdominal pressure, this rationale does not address the critical concern of preventing aspiration in tracheoesophageal fistula. .

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.