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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Teeth: It is typical for infants to start getting their first teeth between 6 and 10 months. The infant in this scenario already has two lower central incisors, which is normal and does not need to be reported.
B. Weight: The infant's weight of 7.26 kg (16 lb) is within the expected range for a 6-month-old. Infants typically double their birth weight by 5 to 6 months of age, and this infant has almost reached that milestone, so the weight is not a concern.
C. Speech: By 6 months, most infants begin to make cooing sounds and may start attempting to imitate speech. That the infant makes cooing sounds but does not attempt to imitate speech is slightly concerning, as by 6 months, some infants are beginning to imitate speech sounds.
D. Temperature: The infant's temperature of 37.1°C (98.8°F) is within the normal range for an infant and does not indicate any issue. There is no need to report this finding to the provider.
Correct Answer is C
Explanation
A. Prolonged crying: Prolonged crying can occur after an immunization, especially in infants, but it is generally not an immediate cause for concern unless accompanied by other symptoms such as difficulty breathing or skin changes.
B. Temperature 37.7° C (99.9° F): A mild fever is a common side effect after immunizations and is usually not a cause for immediate concern. A temperature of 37.7°C (99.9°F) is within a normal range and typically resolves on its own.
C. Hives on the child's neck: Hives (urticaria) can indicate an allergic reaction, which could potentially be a serious response to the immunization. An allergic reaction requires immediate attention and intervention, as it may progress to more severe symptoms such as difficulty breathing or anaphylaxis.
D. Redness at the injection site: Redness at the injection site is a common and expected reaction following an immunization. It is generally not a cause for concern unless it is accompanied by severe swelling, pain, or other signs of infection.
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