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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?

A.

Position the infant supine.

B.

Initiate contact precautions.

C.

Ensure a latex-free environment.

D.

Restrict visitors to immediate family members.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Positioning the infant supine is not the most appropriate intervention for an infant diagnosed with spina bifida who is scheduled for a surgical closure of the myelomeningocele sac. This position could put pressure on the sac and potentially lead to rupture or infection.
Choice B rationale
While contact precautions can be important in certain situations to prevent the spread of infection, they are not the primary intervention for a child with spina bifida undergoing surgery. The main concern is protecting the myelomeningocele sac from damage and infection.
Choice C rationale
Ensuring a latex-free environment is crucial for a child with spina bifida. Many children with spina bifida have a latex allergy, and exposure to latex can cause an allergic reaction. This can range from skin redness and itching to more serious symptoms such as wheezing and difficulty breathing.
Choice D rationale 
Restricting visitors to immediate family members is not specifically related to the care of an infant with spina bifida. While limiting visitors can help reduce the risk of infection, it is not the primary concern in this case.
 


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Related Questions

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

  1. WBC count: This finding is not consistent with either sickle cell anemia or hemophilia. Both conditions do not typically cause an increase in white blood cell count.
  2. Temperature: This finding is not consistent with either sickle cell anemia or hemophilia. Neither condition is associated with an elevated body temperature unless there is a concurrent infection.
  3. Bleeding: This finding is consistent with hemophilia. Hemophilia is a bleeding disorder where the blood does not clot properly. This can lead to spontaneous bleeding as well as bleeding following injuries or surgery.
  4. Reported pain: This finding is consistent with sickle cell anemia. Sickle cell anemia can cause episodes of pain when sickle-shaped red blood cells block blood flow through tiny blood vessels to your chest, abdomen and joints. Pain can also occur in your bones.

Correct Answer is D

Explanation

Choice A rationale
While fat-soluble vitamins are essential for overall health, they do not specifically prevent iron deficiency anemia. Iron deficiency anemia occurs when the body doesn’t have enough iron to produce hemoglobin, the part of red blood cells that gives them their red color and enables them to carry oxygen in the blood.
Choice B rationale
Limiting intake of high-protein foods is not a recommended method for preventing iron deficiency anemia. In fact, many high-protein foods, such as meat and eggs, are good sources of iron.
Choice C rationale
While fluoridated water can help prevent tooth decay, it does not prevent iron deficiency anemia. Iron deficiency anemia is prevented by consuming adequate amounts of iron, either from food sources or from supplements.
Choice D rationale
A diet that consists primarily of milk, particularly cow’s milk, can contribute to iron deficiency anemia. Cow’s milk is low in iron and can also decrease absorption of iron and irritate the lining of the intestine, causing small amounts of bleeding and the gradual loss of iron in the stool (poop)4.

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