A nurse is assessing a school-age child whose blood glucose level is 280 mg/dL. Which of the following findings should the nurse expect?

A) Places the infant in a side-lying position:

Positioning is important in the care of an infant with myelomeningocele. The infant is usually placed in a prone (on the abdomen) position to prevent pressure on the sac and protect the neural tissue. Placing the infant in a side-lying position may not provide the needed protection.

B) Maintains a dry dressing over the sac:

This action indicates effective teaching. The sac should be covered with a sterile, non-stick dressing to protect the exposed neural tissue from infection and trauma. Keeping the dressing dry is important to prevent complications

C) Performs range of motion on the infant's hips:

Range of motion exercises are not typically performed on the hips of an infant with myelomeningocele. The focus of care is primarily on protecting the exposed neural tissue, preventing infection, and ensuring proper positioning.

D) Takes an axillary temperature:

Taking an axillary temperature is a common method for measuring an infant's body temperature. However, in the case of an infant with myelomeningocele, it's important to avoid any pressure or friction on the sac area. The nurse should use care to prevent disturbing the dressing or causing discomfort to the infant.

A. Assume you made a mistake and report out the same head circumference as before.

Incorrect Explanation: Assuming a mistake without taking proper action might not be the best approach.

Explanation: While it's good to consider the possibility of human error, healthcare professionals should prioritize accurate measurements and follow appropriate protocols when discrepancies arise.

B. Take Vital Signs.

Incorrect Explanation: Taking vital signs might not directly address the concern about the head circumference measurement.

Explanation: Vital signs (like heart rate, respiratory rate, blood pressure) are important indicators of a patient's overall health, but they may not directly address the issue of the head circumference measurement discrepancy.

C. Report to the MD/NP/PA in charge of the patient the head circumference that you obtained as well as the patient's current status. Expect that they will also re-measure.

Correct Explanation: This is the best next step.

Explanation: When there's a discrepancy in a critical measurement like head circumference, it's important to communicate this to the responsible healthcare provider (MD/NP/PA). They need to be aware of any changes in the patient's condition and measurements, and they will likely want to re-measure or reassess the situation themselves to ensure accuracy.

D. Move your measuring tape to above the mid-forehead, so that your number matches the findings from the week before.

Incorrect Explanation: Fudging measurements to match previous data is not a professional or ethical approach.

Explanation: Altering measurements to match previous values, especially without proper indication, is not a responsible practice in healthcare. It's essential to ensure accurate and honest documentation.