A nurse is assisting with the care of a newborn who has a myelomeningocele. The nurse should ensure that which of the following supplies is available at the bedside?
Latex gloves
Soft restraints
Sterile saline
Rectal thermometer
The Correct Answer is C
A. Latex gloves: Latex gloves should be avoided, especially in newborns, due to the risk of allergic reactions. Non-latex gloves are the preferred option for any care involving newborns.
B. Soft restraints: Soft restraints are not necessary for the care of a newborn with a myelomeningocele unless there is a specific concern for the infant’s safety. Restraints should not be routinely used unless deemed absolutely necessary.
C. Sterile saline: Sterile saline is essential for cleaning and maintaining the integrity of the myelomeningocele sac. The sac should be kept moist with sterile saline to prevent it from drying out or becoming infected. This is a critical to have at the bedside for proper care.
D. Rectal thermometer: A rectal thermometer should be avoided in infants with a myelomeningocele, especially if the sac involves the lower spinal cord, as it can potentially cause injury to the delicate tissue or result in a risk of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}
Explanation
- Maintain infant in supine position: Given the infant's respiratory distress, including labored breathing, retractions, and nasal flaring, placing the infant in a supine position could worsen respiratory difficulties. The infant should be kept upright or in a semi-Fowler’s position to promote optimal breathing.
- Prepare the infant for a chest x-ray: A chest x-ray is crucial to assess the infant’s respiratory status and potential cardiac issues to identify any underlying causes of the symptoms, such as pneumonia, wheezing, cough, and labored breathing.
- Maintain infant on continuous pulse oximetry: Continuous pulse oximetry is essential for monitoring the infant's oxygen saturation levels. The infant is already on supplemental oxygen, and continuous monitoring will ensure that the oxygen levels are maintained and help identify any worsening of the respiratory condition.
- Monitor intake and output: Given the infant's poor feeding (consuming only half a bottle in the past 24 hours), monitoring intake and output is crucial to assess hydration status and nutritional needs. Decreased intake and output can indicate dehydration or worsening of the infant's condition.
- Initiate a peripheral IV line: Due to the infant’s poor feeding and the possibility of dehydration, establishing a peripheral IV line will allow for proper hydration and the administration of fluids or medications, as necessary, for the infant’s condition.
- Offer small, frequent feedings: Offering small, frequent feedings is appropriate for an infant with respiratory distress and decreased appetite. This can reduce the risk of aspiration and help ensure the infant receives adequate nutrition despite the difficulty with feeding.
Complete the following sentence by using the lists of options.
The nurse should recommend to
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Rationale for Correct Choices:
- Check the child's oropharynx: The child has had a tonsillectomy and is showing signs of possible bleeding, indicated by the small amount of bleeding in the posterior pharynx and bright red emesis (vomiting of blood). The nurse should check the oropharynx to assess the amount and source of the bleeding, as this could indicate a complication post-surgery.
- Obtaining a set of vital signs: After vomiting bright red emesis, it is crucial to assess the child's vital signs to monitor for signs of bleeding or shock. Changes in vital signs, especially increased heart rate or decreased blood pressure, could indicate significant blood loss.
Rationale for Incorrect Choices:
- Offer the child a red popsicle: Red-colored foods are generally avoided post-tonsillectomy as they can obscure or be mistaken for blood. More importantly, offering anything by mouth is contraindicated during active bleeding due to the risk of aspiration and potentially dislodging clots.
- Place the child in a supine position: The child should be positioned in a way that allows for the drainage of blood and secretions, ideally with the head elevated. Placing the child in a supine position could cause blood to pool in the throat, increasing the risk of aspiration.
- Encouraging the child to cough and deep breathe: Encouraging coughing and deep breathing immediately after tonsillectomy is not recommended, as it could dislodge a clot or exacerbate bleeding.
- Requesting a prescription for codeine: Although the child is experiencing some pain (rated 3/10), the primary concern at this point is bleeding, not pain. Pain management should be adjusted but the focus should be on addressing the bleeding first.