A nurse is assisting with the care of an infant who has myelomeningocele.
Which of the following actions should the nurse take?
Apply a sterile, moist dressing on the sac.
Monitor the infant's temperature rectally.
Encourage the guardian to cuddle with the infant.
Maintain the infant in a supine position.
The Correct Answer is A
Choice A rationale
Applying a sterile, moist dressing on the sac helps prevent infection and keeps the tissue moist, promoting healing.
Choice B rationale
Monitoring the infant's temperature rectally can increase the risk of infection and is not recommended.
Choice C rationale
Encouraging the guardian to cuddle with the infant is important for bonding but doesn't directly address the care of myelomeningocele.
Choice D rationale
Maintaining the infant in a supine position can put pressure on the sac, increasing the risk of rupture and infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Babies at around 6 months are developing object permanence and might experience anxiety if they cannot see familiar faces, such as their mother's due to the mask.
Choice B rationale
Hunger is a common cause of crying in infants but doesn't specifically relate to the scenario provided regarding the mask.
Choice C rationale
Cold can cause discomfort in infants, leading to crying, but this is more of a general response and not directly related to the mask scenario.
Choice D rationale
Stress can cause crying, but the specific trigger in the scenario is the mother's masked face, causing potential anxiety.
Correct Answer is B
Explanation
Choice A rationale
HIPAA is indeed a federal law, which sets national standards for the protection of health information. It applies across all states and helps ensure the privacy and security of patients' medical records and other health information.
Choice B rationale
This statement is incorrect and indicates a need for further instruction. HIPAA requires that protected health information (PHI) is only disclosed to family members with the patient's consent, unless under specific circumstances, such as in emergencies or when the patient is incapacitated.
Choice C rationale
HIPAA establishes regulations to protect health information in all forms, including verbal, electronic, and written. This ensures comprehensive coverage of patient data privacy and security across different mediums.
Choice D rationale
A client's address is considered personally identifiable information (PII) under HIPAA. This type of information must be protected to prevent unauthorized access or disclosure, in order to safeguard the individual's privacy. .
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