A nurse is caring for an infant who has spina bifida. Which of the following actions should the nurse take?
Place the infant in prone position.
Cover the infant's lesion with a dry cloth.
Feed the infant through an NG tube.
Diapering over a low defect will keep the infant free from infection
The Correct Answer is D
A. Place the infant in prone position.
This option is incorrect. Placing the infant in the prone position (lying on the stomach) could put pressure on the spinal lesion, potentially causing discomfort or complications. It's important to minimize pressure on the affected area in infants with spina bifida.
B. Cover the infant's lesion with a dry cloth.
This option is incorrect. While keeping the lesion clean and dry is important for preventing infection, simply covering it with a dry cloth may not provide adequate protection. Proper wound care techniques, such as using sterile dressings and cleaning the area with prescribed solutions, are typically necessary to prevent infection and promote healing.
C. Feed the infant through an NG tube.
This option is incorrect. While infants with severe forms of spina bifida may have difficulty feeding due to associated complications, such as difficulty swallowing or weak sucking reflexes, feeding through a nasogastric (NG) tube is not a standard intervention for spina bifida itself. Feeding methods would depend on the specific needs and abilities of the infant, and may involve breastfeeding, bottle-feeding, or other methods under the guidance of healthcare professionals.
D. Diapering over a low defect will keep the infant free from infection.
This option is correct. Diapering over a low defect (the opening in the spine caused by spina bifida) helps to keep the area clean and reduce the risk of infection. By properly covering the defect with a diaper, exposure to urine and feces, which can increase the risk of infection, is minimized. Additionally, regular diaper changes and proper hygiene practices are essential for preventing complications in infants with spina bifida.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Drooling:
Drooling can occur post-tonsillectomy due to throat discomfort or swelling. However, it is not specific to hemorrhage. It may result from pain, swelling, or difficulty swallowing.
B. Continuous swallowing:
Continuous swallowing is indeed a clinical manifestation of hemorrhage after a tonsillectomy. The presence of blood in the throat triggers the swallowing reflex, leading to frequent swallowing by the patient. This symptom is characteristic of hemorrhage and requires immediate medical attention.
C. Poor fluid intake:
Poor fluid intake can occur post-tonsillectomy due to pain, discomfort, or nausea. While it can be a concern for overall recovery, it is not specific to hemorrhage.
D. Increased pain:
Increased pain can be associated with hemorrhage, especially if it is sudden, severe, or worsening. However, it is not as specific as continuous swallowing in indicating hemorrhage post-tonsillectomy. Increased pain can also be due to various other reasons such as inflammation, infection, or trauma.
Correct Answer is C
Explanation
A. Coloring book with crayons:
Coloring activities with crayons are typically more suitable for older children who have developed fine motor skills and hand-eye coordination. At 10 months old, infants are still in the early stages of motor development and may not have the dexterity to hold and manipulate crayons effectively. Additionally, infants at this age are more likely to put objects in their mouths, which poses a choking hazard with crayons.
B. Large-piece puzzles:
Puzzles with large pieces can be beneficial for older children's cognitive development by promoting problem-solving skills and hand-eye coordination. However, at 10 months old, infants are still developing their motor skills and may not have the ability to manipulate puzzle pieces effectively. Puzzles with small pieces can also pose a choking hazard for infants.
C. Crib gym:
A crib gym is a suitable toy for a 10-month-old infant as it provides opportunities for visual stimulation, reaching, grasping, and hand-eye coordination development. Crib gyms typically consist of hanging toys or objects that the infant can bat at or grasp while lying in their crib or playpen. This type of toy encourages exploration and interaction while ensuring safety within the confines of the crib.
D. Put-in take-out toy:
Put-in take-out toys involve placing objects into a container and then removing them, which can be engaging for infants. However, while this type of toy may provide some entertainment for a 10-month-old, it may not offer as much visual and tactile stimulation as a crib gym. Additionally, some put-in take-out toys may have smaller parts that pose a choking hazard for infants, so careful supervision is necessary.
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