The practical nurse (PN) is reinforcing the instructions to the parents of a child who had a surgical repair of a myelomeningocele about changing an occlusive dressing on the child's back.
Which statement by the parents indicates that they understand this procedure?
"The purpose of the dressing is to protect the incision from fecal contamination.”.
"The dressing will help dry the sutures for ease of removal.”.
"We should rapidly remove the tape from the edges of the dressing when changing it.”.
"The dressing should be dampened periodically to keep the skin incision moist.”.
The Correct Answer is A
Choice A rationale
Protecting the myelomeningocele surgical incision from fecal contamination is paramount to prevent infection, as the defect is often located in the lumbosacral area. Fecal matter contains a high concentration of microorganisms, and any contamination could lead to serious central nervous system infections like meningitis.
Choice B rationale
The statement that the dressing will help dry the sutures for ease of removal is incorrect. Occlusive dressings are designed to maintain a moist wound environment, which promotes optimal wound healing and reduces scar formation, rather than drying sutures for removal.
Choice C rationale
Rapidly removing tape from the edges of the dressing is an incorrect technique. This can cause skin trauma, including stripping or tearing, especially in infants whose skin is delicate. Tape should be removed slowly and parallel to the skin to minimize epidermal injury.
Choice D rationale
The statement that the dressing should be dampened periodically to keep the skin incision moist is generally incorrect for surgical incisions once an occlusive dressing is applied. The occlusive dressing itself maintains a moist environment underneath, and external dampening could introduce pathogens and compromise the sterile field.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Collecting a urine specimen for electrolytes and protein would provide data related to renal function and fluid balance, but it does not directly address the client's current subjective symptoms of restlessness and apprehension. These symptoms are more indicative of potential hypoxemia or a psychological response to stress, which requires a more immediate and direct assessment and intervention focused on maternal-fetal well-being rather than baseline lab work. Normal urine specific gravity is 1.005-1.030, and protein should be negative.
Choice B rationale
Moving the client into a dorsal recumbent position can actually compress the inferior vena cava, leading to supine hypotensive syndrome, which further compromises placental perfusion and exacerbates fetal distress. This position is contraindicated in laboring clients, particularly when signs of potential distress are present. The ideal position for laboring clients is typically left lateral, which optimizes uterine perfusion and oxygenation.
Choice C rationale
Encouraging the client to push with the next contraction is inappropriate given the client's symptoms of restlessness and apprehension, especially at 42 weeks gestation with chorioamnionitis. These symptoms could indicate evolving fetal distress or a change in maternal status requiring further assessment, not active pushing. Pushing without complete cervical dilation can lead to cervical edema or trauma.
Choice D rationale
Providing information about the baby's status can alleviate the client's anxiety and apprehension by addressing her immediate concerns about the well-being of her fetus. Restlessness and apprehension in a laboring client, particularly with a diagnosis of chorioamnionitis, can be a symptom of hypoxemia or other complications. Open communication and reassurance are crucial in managing maternal stress and promoting a sense of control.
Correct Answer is ["C","D"]
Explanation
Choice A rationale
Pink-tinged urine can be a symptom of various conditions, including kidney issues or urinary tract infections. While individuals with sickle cell crisis can experience kidney complications, pink-tinged urine is not a universal or primary manifestation of a vaso-occlusive crisis. The immediate priority is pain management and infection prevention.
Choice B rationale
Palpitations, an awareness of one's own heartbeat, can be a symptom of various cardiac issues or a physiological response to stress or pain. While the heart rate is elevated (140 bpm, normal for a toddler is 90-140 bpm), this is likely secondary to the severe pain the child is experiencing and not the primary problem to be addressed.
Choice C rationale
Acute pain is a hallmark and often excruciating symptom of a sickle cell crisis, resulting from vaso-occlusion and tissue ischemia. The toddler's crying, restlessness, and aversion to touch strongly indicate severe pain, making it an immediate priority for intervention to alleviate suffering and prevent further complications.
Choice D rationale
Risk for infection is a significant concern in sickle cell disease due to functional asplenia, which compromises the immune system's ability to fight encapsulated bacteria. Despite the normal oxygen saturation, the elevated temperature (102°F or 38.8°C) in a child with sickle cell disease warrants immediate attention due to the high risk of severe infection.
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