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 ["C","E"]
Explanation
A. Deep tendon reflexes are not mentioned in the notes, and there are no indications that they are abnormal or concerning based on the information provided.
B. The respiratory rate is within normal limits and is not significantly abnormal. There are no indications in the notes to suggest respiratory distress or other respiratory issues.
C. The client's symptoms of a severe headache, dizziness upon standing, and inability to remove rings, along with the elevated blood pressure, suggest potential cerebral
manifestations such as preeclampsia. These symptoms warrant further evaluation and intervention by the provider.
D. Fetal heart rate is within normal limits and does not indicate any immediate concerns based on the information provided.
E. The elevated blood pressure (160/96 mm Hg) is a significant finding and may indicate hypertension or preeclampsia, which requires immediate attention from the provider.
F. Gastrointestinal assessment findings are not mentioned in the notes, and there are no
indications of gastrointestinal issues that would warrant reporting to the provider at this time.
Correct Answer is A
Explanation
A. "I'll let my baby drain one breast at each feeding."
Rationale:
A. "I'll let my baby drain one breast at each feeding." This statement indicates understanding because allowing the baby to empty one breast at each feeding helps in relieving breast engorgement by effectively removing milk. It promotes better milk flow and prevents overproduction.
B. Feeding the baby every 2 hours is a common recommendation, but it may not specifically address breast engorgement management.
C. Cold compresses can help reduce discomfort from engorgement, but they should be applied after feeding, not before.
D. While herbal teas can sometimes provide relief for engorgement, this statement does not address the direct management of engorgement through breastfeeding techniques.
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