A nurse is caring for a newborn who has a myelomeningocele and is admitted to the newborn intensive care unit (NICU) to await surgery. Which of the following nursing goals is priority in the care of this infant?
Promote maternal-infant bonding
Provide age-appropriate stimulation.
Educate the parents about the defect.
Maintain integrity of the sac.
The Correct Answer is D
A. Promote maternal-infant bonding: While promoting maternal-infant bonding is essential for the overall well-being of the newborn and family, it may not be the priority in this situation. The immediate focus is on medical management and preventing complications associated with the myelomeningocele.
B. Provide age-appropriate stimulation: Age-appropriate stimulation is important for newborn development, but in the case of a newborn with a myelomeningocele awaiting surgery, the priority is to minimize any potential risk of injury or infection to the exposed neural tissue.
C. Educate the parents about the defect: Education about the myelomeningocele and its long-term implications is crucial for the parents' understanding and ability to care for their child. However, while important, this may not be the priority at the immediate moment.
D. Maintain integrity of the sac: This is the priority nursing goal in caring for a newborn with a myelomeningocele awaiting surgery. The sac covering the exposed neural tissue must be carefully protected to prevent infection and further damage. Measures such as keeping the sac moist with sterile saline dressings and preventing trauma to the area are essential to maintain its integrity.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "When I use this technique the medication will not run out of the ear."
This explanation is not entirely accurate. While pulling the auricle down and back may help prevent ear drops from immediately dripping out of the ear, the primary purpose of this technique is to straighten the ear canal, facilitating the passage of the medication into the inner ear region for optimal effectiveness. The prevention of medication runoff is a secondary benefit.
B. “This opens the ear canal, allowing medication to reach the inner ear region.”
This explanation is correct. Pulling the auricle down and back helps to straighten the ear canal, making it easier for the ear drops to enter the ear canal and reach the inner ear where they can effectively treat the condition. This is the main purpose of using this technique.
C. “This is the safest and easiest way to administer this medication.”
While pulling the auricle down and back is a commonly used technique for administering ear drops, describing it as the safest and easiest way may not fully capture its purpose. Safety and ease of administration are important considerations, but the primary rationale for this technique is to facilitate the delivery of medication to the inner ear.
D. “When I use the technique, your child experiences less pain.”
This explanation is inaccurate. Pulling the auricle down and back may not directly reduce pain. The main purpose of this technique is to ensure that the medication reaches the inner ear region for effective treatment. While discomfort during administration may be minimized with proper technique, the primary focus is on medication delivery rather than pain reduction.
Correct Answer is ["B","C"]
Explanation
A. "You should begin to manipulate the infant's bedtime based on the hospital's visiting hours."
This statement is incorrect. Manipulating the infant's bedtime based on hospital visiting hours may disrupt the infant's regular sleep schedule, potentially causing discomfort and distress. It's important to maintain the infant's routine as much as possible to promote comfort and well-being.
B. "You should bring the infant's favorite blanket to the hospital."
This statement is correct. Bringing the infant's favorite blanket or comfort item can provide familiarity and comfort during the hospital stay. Having familiar items from home can help soothe the infant and reduce anxiety associated with the new environment.
C. "You should read the child a story about hospitalization."
This statement is correct. Reading a story about hospitalization to the child can help prepare them for the upcoming experience and alleviate fear or anxiety. Choosing age-appropriate books that explain what to expect during a hospital stay can help normalize the experience and provide reassurance to the infant and parents.
D. "You will need to go home when it is not visiting hours."
This statement is incorrect. Parents are typically allowed to stay with their infant throughout the hospitalization, especially in the case of pediatric patients. Family presence is important for providing comfort and support to the infant and facilitating bonding during the hospital stay.
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