A nurse is caring for an infant who has spina bifida.
Which of the following actions should the nurse take?
Feed the infant through an NG tube.
Place the infant in a prone position.
Cover the infant’s lesion with a dry cloth.
Perform range-of-motion (ROM) exercises to the infant’s hips.
The Correct Answer is B
Choice A rationale
Feeding an infant with spina bifida through an NG tube may not be necessary unless the child has specific feeding difficulties or other health issues. Spina bifida does not typically affect a child’s ability to eat or swallow.
Choice B rationale
Placing an infant with spina bifida in a prone position can help protect and care for the lesion on their back. It can also help prevent pressure sores and promote comfort.
Choice C rationale
Covering the infant’s lesion with a dry cloth is not typically recommended. The lesion should be kept clean and moist to promote healing and prevent infection.
Choice D rationale
While physical therapy and exercises can be beneficial for children with spina bifida, performing range-of-motion exercises to the infant’s hips may not be necessary unless specifically recommended by a healthcare provider.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale
Inserting medication in the buccal cavity is an appropriate method for administering oral medication to an infant. The buccal cavity is the area between the cheek and gums, and medication placed here is absorbed directly into the bloodstream.
Choice B rationale
Wrapping the infant in a blanket can provide comfort and security during medication administration, making it easier for both the parent and the infant.
Choice C rationale
Positioning the infant in a supine position during oral medication administration is not safe. This position increases the risk of aspiration, which can lead to choking.
Choice D rationale
Administering medication with an oral syringe is an appropriate method for giving oral medication to an infant. It allows for accurate dosing and can be directed towards the cheek to prevent choking.
Correct Answer is B
Explanation
Choice A rationale
Measuring from the back of the head to the forehead is not the correct method for measuring head circumference in an infant. The measurement should be taken around the widest part of the head, which is typically above the eyebrows and ears.
Choice B rationale
Placing the measuring tape above the eyebrows and around the widest part of the head is the correct method for measuring head circumference in an infant. The tape should be wrapped around the head at the points just above the eyebrows, above the ears, and around the back where the head slopes up prominently from the neck.
Choice C rationale
Measuring from the chin to the top of the head is not the correct method for measuring head circumference in an infant. The measurement should be taken around the widest part of the head, which is typically above the eyebrows and ears.
Choice D rationale
Wrapping the measuring tape tightly around the neck is not the correct method for measuring head circumference in an infant. The measurement should be taken around the widest part of the head, which is typically above the eyebrows and ears.
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