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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
Choice A rationale:
This response acknowledges the client's feelings, addresses the immediate situation, and offers an alternative without judgment.
Choice B rationale:
Asking "What's wrong? Haven't you ever lost a game before?”. might come across as dismissive and insensitive to the client's emotions.
Choice C rationale:
Simply saying "I am sure you'll win the next game”. minimizes the client's feelings and does not address the current situation.
Choice D rationale:
Telling the client that "other children will not want to play with you if you act like that”. is a negative and shaming response, which is counterproductive to building a therapeutic relationship.
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