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
While it’s important to explain to a child why they are receiving medication, simply telling them that it will make them feel better may not be enough to alleviate their fear or anxiety about receiving an injection.
Choice B rationale
Asking the parents to hold the child during an injection can be traumatic for both the child and the parent. It’s generally recommended to have a trained healthcare professional hold the child in a safe and secure manner.
Choice C rationale
Allowing the child to hold a favorite toy can provide comfort and distraction during the injection.
Choice D rationale
While it might seem like a good idea to administer the medication in the child’s room where they feel safe, this can actually make the child associate their safe space with negative experiences.
Correct Answer is B
Explanation
Choice A rationale
While assistance may be needed to comfort the toddler during the procedure, holding the toddler in a prone position is not the recommended position for a lumbar puncture.
Choice B rationale
Placing the toddler in a side-lying, knee-chest position is the correct position for a lumbar puncture. This position helps to open up the spaces between the vertebrae, making it easier to access the spinal canal.
Choice C rationale
Restraining the toddler for 1 hour after the procedure is not necessary and could cause distress to the toddler.
Choice D rationale
While swaddling the toddler in a warm blanket may provide comfort, it is not a necessary step in the administration of a lumbar puncture.
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