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","D"]
Explanation
A. Cranberry juice
Cranberry juice may be too acidic and could irritate the surgical site. It's best to avoid acidic beverages immediately following a tonsillectomy.
B. Ice-cream
This option is suitable. Ice-cream is cold and soothing, and it can help numb the throat, providing relief from discomfort after a tonsillectomy. However, it's essential to ensure that the ice-cream is not too cold to avoid causing discomfort.
C. Hot tea
Hot tea is not recommended immediately following a tonsillectomy. Hot liquids can irritate the surgical site and may cause discomfort. It's best to avoid hot beverages until the throat has had time to heal.
D. Italian ice
Italian ice is a frozen dessert similar to a slushy, and it can be a suitable option after a tonsillectomy. Like ice-cream, Italian ice is cold and can help numb the throat, providing relief from discomfort.
Correct Answer is D
Explanation
A. A 45-degree head elevation: This position can help facilitate venous drainage and reduce intracranial pressure. Elevating the head of the bed may aid in preventing the accumulation of cerebrospinal fluid (CSF) in the brain, which is important after VP shunt insertion to maintain proper drainage. However, this position alone may not be sufficient.
B. On the nonoperative side: Placing the child on the nonoperative side can help reduce pressure on the side where the shunt was inserted, minimizing discomfort and the risk of disruption or displacement of the shunt. However, this position may not directly affect CSF drainage.
C. Prone: Placing the child prone (lying face down) is generally not recommended after VP shunt insertion. This position may increase pressure on the head and interfere with proper CSF drainage, potentially leading to complications.
D. Supine: Placing the child supine (lying on their back) is typically recommended after VP shunt insertion. This position helps promote proper drainage of CSF through the shunt system without placing undue pressure on the surgical site. It also allows for easy monitoring of the child's condition and surgical site.
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