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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

- A: Plantar creases covering 2/3 of the sole is indicative of a more mature newborn, which is a significant finding in assessing gestational age.
- B: Acrocyanosis of hands and feet is a common finding in the first few days after birth and is not specifically related to gestational age.
- C: The condition of the anterior fontanel being soft and level is a normal finding and does not contribute to the assessment of gestational age.
- D: The presence of vernix caseosa in inguinal creases can be seen in both preterm and full-term newborns, thus it is not a specific indicator of gestational age.

A. Change the perineal pad of a client who just transferred from labor and delivery. B. Observe an area of redness on the breast of a client who is 1 day postpartum. C. Monitor vital signs during admission of a client who has gestational hypertension. D. Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum.

Correct Answer is A

Explanation

A. Changing the perineal pad is a task that can be safely delegated to an assistive personnel (AP) as it involves basic hygiene care and does not require nursing judgment.
B. Observing an area of redness on the breast may require nursing assessment and judgment to determine if further intervention is needed.
C. Monitoring vital signs during admission of a client with gestational hypertension requires nursing assessment and judgment to detect any signs of worsening condition or complications.
D. Providing a sitz bath to a client with a fourth-degree laceration requires nursing assessment and judgment to ensure appropriate wound care and pain management.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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