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 B
Explanation
A. Monitoring the newborn's blood pressure may be indicated in some situations but is not the priority in this case, as the symptoms described suggest hypoglycemia rather than hypertension.
B. Obtaining blood glucose by heel stick is the priority action. The symptoms of diaphoresis, jitteriness, and lethargy are indicative of hypoglycemia in newborns, and obtaining a blood glucose level will confirm the diagnosis and guide appropriate treatment.
C. Placing the newborn in a radiant warmer may help to prevent heat loss but does not address the underlying issue of hypoglycemia.
D. Initiating phototherapy is not indicated for the symptoms described, which suggest hypoglycemia rather than hyperbilirubinemia.
Correct Answer is C
Explanation
A. Absent plantar reflexes may indicate neurological issues but are not specifically associated with developmental dysplasia of the hip (DDH).
B. Lengthened thigh on the affected side is not a typical finding in DDH. Instead, there may be apparent shortening due to hip dislocation.
C. Asymmetric thigh folds are a common finding in DDH due to hip instability, causing the femoral head to be displaced from the acetabulum and resulting in uneven thigh folds.
D. An inwardly turned foot on the affected side may be seen in conditions like clubfoot but is not a characteristic finding in DDH.
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