A nurse is caring for a newborn who has myelomeningocele. Which of the following nursing goals has the priority in the care of this infant?
Educate the parents about the defect.
Maintain the integrity of the sac.
Provide age-appropriate stimulation.
Promote maternal-infant bonding.
The Correct Answer is B
A. Educating the parents about the defect is important for their understanding and involvement in the care of the newborn, but it is not the priority when the infant has a myelomeningocele.
B. Maintaining the integrity of the sac is the priority goal in the care of a newborn with myelomeningocele to prevent infection and protect the exposed neural tissue.
C. Providing age-appropriate stimulation is important for the overall development of the newborn but is not the priority when the infant has a myelomeningocele.
D. Promoting maternal-infant bonding is essential for the emotional well-being of both the
mother and the newborn, but it is not the priority when immediate physical care needs exist, such as maintaining the integrity of the sac.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Not passing meconium within 24 hours may indicate meconium ileus or another bowel obstruction, but it's not an immediate concern.
B. A temperature of 37.5°C (99.5°F) is within the normal range for a newborn and does not require immediate intervention.
C. Acrocyanosis, blueness of the extremities, is a common finding in newborns and does not require immediate intervention.
D. A newborn who is 24 hours post-delivery and has not voided requires immediate intervention as it may indicate a urinary tract obstruction or another issue that needs prompt assessment and management.
Correct Answer is A
Explanation
A. Checking the baby's temperature rectally every hour is unnecessary and may cause discomfort and potential harm to the baby. Temperature checks should be done as per healthcare provider's
recommendation.
B. Keeping the baby's head covered helps regulate their body temperature and prevents heat loss, especially in newborns who are more prone to heat loss from their heads.
C. Keeping the baby's bassinet away from fans and air conditioning helps maintain a stable and comfortable temperature for the newborn, preventing overheating or chilling.
D. Placing the baby on the stomach (prone position) is not recommended for sleep due to the increased risk of sudden infant death syndrome (SIDS). Infants should be placed on their back to sleep.
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