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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. Polyuria is more commonly seen in hyperglycemia, not hypoglycemia, so it is unlikely to be present with a blood glucose level of 55 mg/dL.

B. Dry, flushed skin is typically a sign of hyperglycemia (e.g., in diabetic ketoacidosis), not hypoglycemia.

C. Deep, rapid respirations are a symptom of metabolic acidosis or severe hyperglycemia, not hypoglycemia.

D. Tachycardia is a common compensatory response to hypoglycemia, as the body tries to increase glucose delivery to tissues.

A. Measure weight and height. B. Insert an indwelling urinary catheter. C. Initiate IV access. D. Maintain ECG monitoring.

Correct Answer is C

Explanation

A. Measuring weight and height is not an immediate priority in the management of shock.

B. Inserting an indwelling urinary catheter is not a priority in the early management of shock.

C. Initiating IV access is crucial for fluid resuscitation and medication administration in a child with shock.

D. While ECG monitoring is important, it is not as immediately necessary as establishing IV access for shock management.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is assessing an 8-year-old child who has early indications of shock. After establishing and stabilizing the child's respirations, which of the following actions should the nurse take next?

Correct Answer is C

Explanation

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