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. Call the child abuse hotline. A spiral fracture, especially in a non-ambulatory infant, is highly suspicious for non-accidental trauma (child abuse). Reporting suspected abuse is mandatory to protect the child from further harm.
B. Educate the mother on safety. While important for prevention, addressing potential abuse takes precedence.
C. Inform the mother to call the nurse for all diaper changes. This does not address the immediate concern of suspected child abuse.
D. Complete the Morse Fall Scale. This is irrelevant in the context of suspected child abuse.

Correct Answer is ["0.3"]

Explanation

Convert weight from pounds to kilograms:

19pounds÷2.2=8.64kg

Calculate the total daily dose:

0.07mg/kg/day×8.64kg=0.6048mg/day

Divide the daily dose into two doses:

0.6048mg/day÷2=0.3024mg/dose

Round off the dose to two decimal places:

0.3024mg≈0.30mg

The maximum amount of medication per dose is 0.3 mg.

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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 newborn is admitted with a diagnosis of a spiral fracture of the right femur. The mother states the child received the injury when the baby fell off the changing table. Which would be the priority nursing intervention?

Correct Answer is A

Explanation

A child with a heart defect is placed on a maintenance dose of Lanoxin elixir. The ordered dose is 0.07mg/kg/day in 2 divided doses. The child weighs 19 pounds. What is the maximum amount of medication that will be given per dose by the nurse?

Correct Answer is ["0.3"]

Explanation

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