A nurse is caring for a newborn who was born 6 hr ago.
Complete the diagram by dragging from the choices below to specify what condition the newborn is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the newborn's progress.
The Correct Answer is []
Potential condition
Correct Answer: B. Meningocele
Rationale: Based on the provided physical examination details, the newborn is most likely experiencing a meningocele, which is indicated by the presence of a sac in the lumbar area. This condition is a type of neural tube defect where a sac of fluid comes through an opening in the baby's back. However, the absence of other neurological symptoms and the intact reflexes suggest that the condition has not severely affected the newborn's neurological functions.
Actions to Take (2)
Correct Answers: C, E
The two actions the nurse should take to address this condition include: applying a non-adhering sterile saline moist compress to the sac to prevent it from drying and to protect it from trauma, and educating the guardians about the condition, its implications, and the potential need for surgical intervention to repair the defect.
Parameters to monitor
Correct Answer: A, C
Rationale: The two parameters the nurse should monitor to assess the newborn's progress are the head circumference and serial head ultrasounds. Monitoring head circumference is crucial as an increase may indicate hydrocephalus, which can be associated with meningocele. Serial head ultrasounds are necessary to assess for any changes in the brain structure or development of hydrocephalus. These measures will help ensure that any complications are identified and managed promptly.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. A heart rate of 130/min is elevated and may indicate continued dehydration or stress. It does not necessarily indicate the effectiveness of oral rehydration therapy.
B. A capillary refill greater than 3 seconds indicates poor perfusion and ongoing dehydration. It does not indicate the effectiveness of oral rehydration therapy.
C. A respiratory rate of 24/min is within normal range for a 3-year-old child. It does not necessarily indicate the effectiveness of oral rehydration therapy.
D. A urine specific gravity of 1.015 indicates adequate hydration. Normal urine specific gravity typically ranges from 1.005 to 1.030, and a value closer to 1.015 indicates proper hydration
status. Therefore, this finding suggests that oral rehydration therapy has been effective in restoring fluid balance.
Correct Answer is B
Explanation
Rationale:
A. Obtain a type and crossmatch: While obtaining a type and crossmatch may be necessary in the event of significant hemorrhage, the first action should be to address the potential cause of hypotension, which could be uterine atony.
B. Evaluate the firmness of the uterus: Postpartum hypotension is often caused by uterine atony, so the first action should be to assess the firmness of the uterus and massage it to stimulate contraction if necessary.
C. Administer oxytocin infusion: Oxytocin infusion may be necessary to help contract the uterus and control bleeding, but it should be implemented after assessing uterine firmness.
D. Initiate oxygen therapy by nonrebreather mask: While oxygen therapy may be needed if the client is hypotensive due to hemorrhage, assessing uterine firmness is the priority action to address the potential cause of hypotension.
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