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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Give the child a stuffed animal: Providing a comforting item like a stuffed animal can help the child feel more secure and may offer some comfort during the parent's absence. This option is appropriate as it addresses the child's emotional needs.
B. Inform the child that her parent will be back in 2 hours: While it's helpful to provide reassurance to the child, a 2-year-old may not fully understand the concept of time, and telling them that their parent will return in 2 hours may not effectively alleviate their distress. This option may not be as immediately comforting as providing a tangible source of comfort.
C. Call the parent to return to the child's room: If possible, having the parent return to the child's room can provide the most direct comfort and reassurance to the child during a tantrum. However, it may not always be feasible for the parent to return immediately, especially if they are occupied or attending to other responsibilities.
D. Leave the child alone in the room for 5 minutes: Leaving the child alone during a tantrum can exacerbate feelings of distress and abandonment, potentially escalating the situation further. It's essential to provide support and reassurance to the child during moments of distress rather than leaving them alone.
Correct Answer is B
Explanation
A. Decreased stridor: Stridor is a high-pitched, noisy breathing sound caused by turbulent airflow through a narrowed or partially obstructed airway. In laryngotracheobronchitis, stridor is often present and may worsen with increasing airway obstruction. Therefore, decreased stridor would not be a typical finding associated with airway obstruction in this condition.
B. Increased restlessness: Increased restlessness can be a sign of worsening respiratory distress and impending airway obstruction. As the child struggles to breathe, they may become increasingly agitated and restless, indicating the need for prompt intervention to ensure adequate oxygenation.
C. Decreased heart rate: Decreased heart rate (bradycardia) is not typically associated with airway obstruction in laryngotracheobronchitis. In fact, the heart rate may increase as a compensatory response to hypoxia and respiratory distress.
D. Decreased temperature: Changes in temperature are not typically associated with airway obstruction in laryngotracheobronchitis. The focus of monitoring in this condition is primarily on respiratory distress and signs of worsening airway obstruction.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.