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 B

Explanation

A. The newborn with a heart rate of 154 beats/minute. This is within the normal range for a newborn, which is between 120-160 beats per minute.
B. The newborn with a respiratory rate of 72 breaths/minute. This is abnormal; the normal respiratory rate for a newborn is between 30-60 breaths per minute. A rate of 72 could indicate respiratory distress and requires prompt evaluation.

C. The newborn with a red raised capillary hemangioma on the left forearm. Capillary hemangiomas are common, benign vascular tumors that typically do not require immediate intervention.
D. The newborn with whitish, hardened nodules on the gums of the mouth. These are likely Epstein pearls, which are harmless cysts often seen in newborns and typically resolve on their own.

A. Tachypnea B. Wheezes or rales C. Bounding pulses D. Edematous E. Difficulty feeding F. Increased comfort laying down

Correct Answer is ["A","B","D","E"]

Explanation

A. Tachypnea. Rapid breathing can indicate respiratory distress associated with heart failure.
B. Wheezes or rales. These are abnormal breath sounds indicating fluid in the lungs, which can occur with heart failure.
C. Bounding pulses. Bounding pulses are not typically associated with heart failure; weak pulses may be present due to poor perfusion.
D. Edematous. Edema can occur due to fluid retention, a sign of heart failure.
E. Difficulty feeding. Poor feeding can result from decreased cardiac output affecting systemic circulation and energy for feeding.
F. Increased comfort laying down. Children with heart failure often prefer sitting upright due to respiratory distress.

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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

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Correct Answer is B

Explanation

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Correct Answer is ["A","B","D","E"]

Explanation

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