What is the priority nursing intervention to perform on an infant immediately following repair of a myelomeningocele?

Assess motor function in lower extremities

Maintain skin integrity

Monitor intake and output

Monitor head circumference

Answer and Explanation

The Correct Answer is D

A. Assess motor function in lower extremities: While important for overall neurological assessment, immediate post-repair monitoring of motor function is secondary to monitoring for signs of hydrocephalus (head circumference).
B. Maintain skin integrity: Essential for preventing infection but does not address the immediate post-surgical complication of hydrocephalus.
C. Monitor intake and output: Important for general post-operative care but does not address the immediate concern of monitoring for hydrocephalus.
D. Monitor head circumference: Following repair of a myelomeningocele, infants are at risk for developing hydrocephalus due to abnormal cerebrospinal fluid dynamics. Monitoring head circumference helps detect early signs of increased intracranial pressure, a common complication post-surgery.

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Correct Answer is A

Explanation

A. Pain. Pain is the hallmark symptom of a sickle cell crisis due to the vaso-occlusion of sickled red blood cells blocking blood flow and causing ischemia in various tissues and organs.
B. High fever. While fever can occur if there is an associated infection, it is not a primary feature of sickle cell crisis.
C. Bradycardia. Sickle cell crisis can cause tachycardia due to pain and stress, but not bradycardia.
D. Constipation. This is not a typical symptom associated with a sickle cell crisis.

A. Sole creases on heels B. Ruddy skin color C. Flexion of all four (4) extremities D. Scant amount of vernix caseosa

Correct Answer is D

Explanation

A. Sole creases on heels. Sole creases are a sign of maturity and are usually present in full-term infants, not preterm.
B. Ruddy skin color. This is more common in infants with polycythemia or those who are small for gestational age, not specifically linked to prematurity.
C. Flexion of all four extremities. Premature infants typically have less muscle tone and may exhibit less flexion, often appearing more limp or having extended extremities.
D. Scant amount of vernix caseosa. Premature infants typically have more vernix caseosa, which protects their delicate skin in utero. The amount decreases closer to full term, but at 31 weeks, there may still be a moderate amount.

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What is the priority nursing intervention to perform on an infant immediately following repair of a myelomeningocele?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a child who is in sickle cell crisis. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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