A nurse is caring for a neonate who has a myelomeningocele and is admitted to the newborn intensive care unit (NICU) awaiting surgery. Which of the following nursing goals has the highest priority in the care of this infant?
Provide age-appropriate stimulation.
Educate the parents about the defect.
Promote maternal-infant bonding.
Maintain integrity of the sac.
The Correct Answer is D
A. While stimulation is important, the priority in this case is ensuring the infant’s safety and preventing further injury to the defect.
B. Education is vital but secondary to the immediate physical care needs of the infant.
C. Promoting bonding is important but does not take precedence over maintaining the integrity of the sac.
D. Maintaining the integrity of the sac is the highest priority to prevent infection and further neurological damage.
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Related Questions
Correct Answer is C
Explanation
A. Placing the infant supine in the crib is not a recommended position for administering oral medication as it may cause choking or aspiration.
B. Mixing medication with formula is not recommended, as it may alter the effectiveness of the medication or lead to incomplete dosing.
C. Positioning the syringe to the side of the infant's tongue is the best method to prevent choking and allow the infant to swallow the medication effectively.
D. A medicine cup is not appropriate for measuring medication for an infant due to the small volume and potential for spillage.
Correct Answer is B
Explanation
A. Encouraging large amounts of fluids may not be effective in preventing nausea and vomiting and can worsen dehydration if the child is unable to keep fluids down.
B. Administering an antiemetic 30 minutes to 1 hour before chemotherapy is the most effective strategy for preventing nausea and vomiting. This proactive approach helps to prevent the symptoms before they occur.
C. NPO until symptoms subside is not appropriate because it can lead to dehydration and malnutrition.
D. Administering an antiemetic after symptoms begin is reactive rather than proactive, and it is more effective to prevent symptoms from occurring.
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