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. Using a suction catheter is appropriate but may not be the quickest method for immediate airway clearance in this situation.
B. Suctioning the mouth with a bulb syringe is the priority action as it helps clear the airway of secretions and prevents aspiration, ensuring the newborn can breathe effectively.
C. Turning the newborn on his side can help with drainage but does not actively clear the airway, making it a less immediate priority.
D. Suctioning the nose is important, but the mouth should be cleared first to ensure a patent airway, making this option secondary.
Correct Answer is A
Explanation
A. Rh (D) immunoglobulin, commonly known as Rhogam, is given to Rh-negative mothers to prevent the formation of Rh antibodies if the baby is Rh positive. This prevents Rh sensitization in future pregnancies, which could lead to hemolytic disease of the newborn.
B. Rh (D) immunoglobulin does not destroy Rh antibodies in Rh-negative mothers but rather prevents their formation.
C. Rh (D) immunoglobulin does not prevent the formation of Rh antibodies in Rh-positive
newborns but rather prevents the mother's immune system from producing antibodies against Rh-positive blood cells.
D. Rh (D) immunoglobulin does not destroy Rh antibodies in Rh-positive newborns. It is administered to Rh-negative mothers to prevent antibody formation.
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