A nurse is caring for an infant post operative closure of a myelomeningocele. Which intervention is essential for providing basic care and comfort following myelomeningocele sac closure?

Avoiding any oral feedings for the first 24 hours to prevent aspiration

Applying direct pressure to the surgical site if bleeding occurs.

Frequent diaper changes and keeping the incision site clean and dry

Allowing the infant to lie flat on their back to promote spinal alignment

Answer and Explanation

The Correct Answer is C

A.   Avoiding oral feedings may not be necessary unless there are specific complications. The focus should be on preventing aspiration, but not necessarily withholding feedings.
B.   Direct pressure should not be applied to the surgical site unless directed by a provider, as this could cause further complications.
C.   Frequent diaper changes and keeping the incision site clean and dry is essential to prevent infection and protect the surgical site.
D.   The infant should be positioned according to the provider's orders to avoid pressure on the surgical site and spinal cord, but lying flat may not always be necessary.

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Correct Answer is B

Explanation

A. Jock itch is a fungal infection of the groin, not the feet.
B. Tinea pedis is the medical term for athlete's foot, a fungal infection of the feet.
C. Ringworm is a fungal infection that can affect various parts of the body, not specifically the feet.
D. Poison sumac is a plant-based skin irritation caused by contact with the plant, not a fungal infection.

A. Administer morphine sulfate to help alleviate pain and anxiety. B. Provide supplemental oxygen via nasal cannula. C. Offer the infant a pacifier to calm down. D. Place the infant in a knee to chest position.

Correct Answer is D

Explanation

A. While morphine can help to relieve anxiety and pain, it does not address the underlying cause of a hypercyanotic spell, which is the right-to-left shunting. The first step should be positioning the infant properly.
B. Although oxygen is helpful, it will not be as effective as using the knee-to-chest position to alleviate the underlying circulatory issue causing the hypercyanotic spell.
C. While comforting the child is important, a pacifier will not help in alleviating the hypercyanotic spell and is not the primary intervention in this emergency situation.
D. In a hypercyanotic spell, the priority is to increase systemic vascular resistance to decrease the right- to-left shunting of blood. The knee-to-chest position is effective for this, as it increases the resistance in the lower extremities, helping to improve oxygenation.

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A nurse is caring for an infant post operative closure of a myelomeningocele. Which intervention is essential for providing basic care and comfort following myelomeningocele sac closure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an adolescent client who has tinea pedis. The parents ask the nurse, "What is the common name of this infection?" The nurse should respond with which of the following common names?

Correct Answer is B

Explanation

A nurse is caring for a 6-month-old Infant with a diagnosis of Tetralogy of Fallot (TOF) who is experiencing a hypercyanotic spell. The Infant is lethargic and has a weak cry. What is the priority nursing action for this Infant?

Correct Answer is D

Explanation

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