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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. This response acknowledges the client's concern and provides accurate information about the unpredictability of urinary frequency during pregnancy.
B. While some clients may experience relief from urinary frequency after the first trimester, it is not guaranteed, and poor bladder tone is just one of many factors that can contribute to urinary frequency during pregnancy.
C. This statement is inaccurate as urinary frequency can occur throughout pregnancy due to hormonal changes and pressure from the growing uterus.
D. Dismissing the client's concern as a minor inconvenience is not appropriate and does not address the client's question.
Correct Answer is D
Explanation
Rationale:
A. Headache can be a common side effect of magnesium sulfate but is usually not concerning unless severe or persistent.
B. A fetal heart rate of 158/min is within the normal range for a fetus and is not typically associated with magnesium sulfate administration.
C. Respirations of 16/min are within the normal range and are not typically associated with magnesium sulfate administration.
D. A urinary output of 40 mL in 2 hours is significantly reduced and may indicate magnesium toxicity or impaired renal function, which should be reported to the provider for further
evaluation and management.
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