A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?

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. Dizziness is always a sign of a concussion.

This statement is incorrect. While dizziness can be a symptom of a concussion, it is not always indicative of a concussion. There can be various causes of dizziness, and it is essential to consider other symptoms as well when assessing for a concussion.

B. Bike Helmet Safety

Explanation:

The correct answer to include as part of concussion/head injury prevention teaching to children and parents is "Bike helmet safety." This is because wearing a helmet while riding a bike or participating in other activities that involve head injury risks is crucial to prevent head injuries and concussions. Helmets provide protection to the head by absorbing impact energy and reducing the risk of skull fractures or traumatic brain injuries.

C. Normal fluid intake.

While staying hydrated is important for overall health, it is not directly related to concussion or head injury prevention teaching. This choice is unrelated to the topic.

D. Signs of autism.

Signs of autism are unrelated to concussion or head injury prevention teaching. This choice is not relevant to the topic at hand.