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. 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.

A. Document the findings and continue to monitor the client. B. Increase the frequency of fundal massage. C. Encourage the client to empty her bladder. D. Notify the client's provider.

Correct Answer is A

Explanation

A. The findings described are within the expected range for 1 hour postpartum, as lochia rubra and small clots are normal during the early postpartum period. The firm, midline fundus suggests adequate uterine contraction. Documenting the findings and continuing to monitor the client's progress are appropriate.
B. Increasing the frequency of fundal massage is not necessary as the fundus is already firm and midline.
C. Encouraging the client to empty her bladder is important for uterine involution, but it is not the priority in this scenario, as the fundus is already firm and midline.
D. Notifying the client's provider is not necessary at this time, as the findings are within the expected range for the early postpartum period and do not indicate any immediate complications.

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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

A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

Correct Answer is A

Explanation

A nurse is caring for a client who is 1 hour postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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