A nurse is formulating a care plan for an infant diagnosed with spina bifida who is scheduled for a surgical closure of the myelomeningocele sac.

Which of the following interventions should be incorporated into the care plan?

Choice A rationale
Applying a pressure dressing four hours after discharge is not typically recommended following a cardiac catheterization. The site of the catheter insertion is usually covered with a simple dressing and observed for any signs of bleeding or swelling.
Choice B rationale
While it’s important to monitor for signs of impaired circulation, such as a cool extremity, this is not the primary concern following a cardiac catheterization. The procedure involves inserting a catheter into a blood vessel, not typically affecting the peripheral temperature of the extremities.
Choice C rationale
Administering acetaminophen or ibuprofen for pain as needed is a common recommendation following procedures like a balloon angioplasty. Pain can result from the catheter insertion site and these medications can help manage it.
Choice D rationale
Maintaining a clear liquid diet for 24 hours after discharge is not typically necessary following a cardiac catheterization. Once the child is alert, they are usually provided with clear liquids and later something to eat.

Choice A rationale
Limiting noise and interruption in the delivery room can help create a calm environment, which can be beneficial for both the mother and the newborn. However, this is not the priority action for promoting maternal-infant bonding.
Choice B rationale
Encouraging parents to touch and explore the neonate’s features can help foster a connection between the parents and the newborn. This tactile stimulation can also be comforting for the newborn. However, this is not the most immediate action to promote maternal-infant bonding.
Choice C rationale
Placing the neonate skin-to-skin on the client’s chest is the priority action. Skin-to-skin contact immediately after birth helps regulate the newborn’s temperature, heart rate, and breathing. It also promotes breastfeeding and bonding.
Choice D rationale
Placing the neonate at the client’s breast can promote breastfeeding, which can enhance maternal-infant bonding. However, this is not the first action to take. The priority is to establish skin-to-skin contact.