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:

Inquiring about pain after surgery is a normal concern for a mother, but it doesn't necessarily indicate successful progress in attachment. It shows concern for the baby's well-being, but attachment involves more emotional and bonding aspects.

Choice B rationale:

Expressing joy in seeing the baby empty her formula bottle during feeding demonstrates an emotional connection and maternal satisfaction with providing for the infant's needs. This suggests successful attachment and bonding between the mother and baby.

Choice C rationale:

Concerns about the scar from surgery indicate the mother's focus on the physical appearance of the baby, which is not the primary marker of successful attachment. It reflects a different aspect of the mother's thoughts and emotions.

Choice D rationale:

Noting similarities in physical features doesn't necessarily indicate a deeper attachment. While it's a natural observation, attachment involves more emotional bonding than just physical resemblances.

A. Holds the child's head in an upright position during feeding. B. Places the tip of the syringe in the side of the child's mouth. C. Burps the child frequently during the feeding. D. Places the child in a prone position after feeding.

Correct Answer is D

Explanation

The correct answer is choice d. Places the child in a prone position after feeding.

Choice A rationale:

Holding the child’s head in an upright position during feeding is appropriate as it helps prevent aspiration and ensures proper swallowing.

Choice B rationale:

Placing the tip of the syringe in the side of the child’s mouth is correct because it helps direct the formula to the back of the mouth, reducing the risk of choking.

Choice C rationale:

Burping the child frequently during the feeding is necessary to release any swallowed air, which can help prevent discomfort and spitting up.

Choice D rationale:

Placing the child in a prone position after feeding is incorrect and indicates a need for further instructions. After feeding, the child should be placed in an upright or slightly elevated position to prevent aspiration and reduce the risk of gastroesophageal reflux.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A mother visits her critically ill infant daily. Which comment most strongly suggests this mother is successfully progressing in attachment to her infant?

Correct Answer is B

Explanation

After a cleft lip repair, a child is receiving formula feedings through a syringe. The child's parent is participating in care. Which of these actions by the parent indicates a need for further instructions about feeding the child? The caregiver:.

Correct Answer is D

Explanation

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