Which is the priority nursing intervention for an infant diagnosed with myelomeningocele?

Educating caregivers on sensory impairment.

Preventing infection.

Correction of joint contractures.

Measuring daily head circumference.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

While educating caregivers on sensory impairment is important for an infant with myelomeningocele, preventing infection takes precedence as the priority nursing intervention.

Choice B rationale:

The correct answer. Preventing infection at the site of the myelomeningocele is crucial to avoid potentially life-threatening complications, such as meningitis. The exposed neural tissue poses a significant infection risk.

Choice C rationale:

Correcting joint contractures is important but is a secondary concern compared to preventing infection, which can have more immediate and severe consequences.

Choice D rationale:

Measuring daily head circumference is important to monitor for hydrocephalus in these infants, but preventing infection remains the higher priority.

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Correct Answer is B

Explanation

Choice A rationale:

Administering pancreatic enzymes between meals may not provide the necessary digestive support when food is introduced to the gastrointestinal tract. These enzymes are meant to aid in digestion, so administering them between meals might not be as effective as when taken in conjunction with food.

Choice B rationale:

Administering pancreatic enzymes before meals is the most appropriate time because it helps replace the missing enzymes in patients with cystic fibrosis. These enzymes aid in breaking down food and absorbing nutrients, compensating for the deficient pancreatic function. By giving the enzymes before meals, the body has the necessary support to digest the incoming food.

Choice C rationale:

While administering enzymes during meals might seem logical, it's actually less effective. The enzymes need time to mix with the ingested food before it enters the small intestine, where digestion primarily occurs.

Choice D rationale:

Administering pancreatic enzymes after meals wouldn't be as effective because the enzymes need to be present when food enters the stomach and begins the digestive process.

A. An increasing pulse rate. B. Mouth breathing. C. An increase in nasal discharge. D. A hoarse cry.

Correct Answer is A

Explanation

Choice A rationale:

An increasing pulse rate suggests that the patient's condition is worsening. Tachycardia can indicate increased work of breathing and decreased oxygenation, which are concerning signs in laryngotracheobronchitis.

Choice B rationale:

Mouth breathing is a common response to airway obstruction, such as in laryngotracheobronchitis. While it indicates respiratory distress, it doesn't specifically suggest a worsening of the condition.

Choice C rationale:

An increase in nasal discharge might be seen with the common cold or other upper respiratory infections but is not a specific indicator of worsening laryngotracheobronchitis.

Choice D rationale:

A hoarse cry is a characteristic symptom of laryngotracheobronchitis due to inflammation of the airway. However, it is a common initial symptom and may not directly correlate with worsening of the condition.

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Which is the priority nursing intervention for an infant diagnosed with myelomeningocele?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When a client with cystic fibrosis is prescribed pancreatic enzymes, what is the best time for the nurse to administer them to the client?

Correct Answer is B

Explanation

A patient is admitted from the emergency room with laryngotracheobronchitis. The patient has a brassy cough, stridor, and substernal retractions. The child is receiving an intravenous infusion and is placed in a mist tent. Which observation would indicate a worsening of the patient's condition?

Correct Answer is A

Explanation

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