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?
Position the infant supine.
Initiate contact precautions.
Ensure a latex-free environment.
Restrict visitors to immediate family members.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Depressed fontanels are not typically associated with increased intracranial pressure (ICP) in infants. In fact, bulging fontanels may be a sign of increased ICP1516.
Choice B rationale
A brisk pupillary reaction to light is not a specific sign of increased ICP in infants. Changes in pupillary reaction can occur in various conditions and are not definitive indicators of increased ICP.
Choice C rationale
Increased sleeping is a symptom of increased ICP in infants. However, this symptom alone is not enough to diagnose increased ICP as it can be seen in other conditions as well.
Choice D rationale
Unspecified symptom is not a valid choice as it does not provide a specific symptom to evaluate.
Correct Answer is D
Explanation
Step 1 is: Calculate the Apgar score based on the given vital signs. The Apgar score is calculated based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color.
Step 2 is: Assign points for each criterion. For heart rate of 160 bpm, assign 2 points. For good, vigorous respiratory effort, assign 2 points. For active movement and well-flexed muscle tone, assign 2 points. For crying with stimulation of soles of feet (reflex irritability), assign 2 points. For body pink but feet and hands cyanotic (color), assign 1 point.
Step 3 is: Add up the points. 2 (heart rate) + 2 (respiratory effort) + 2 (muscle tone) + 2 (reflex irritability) + 1 (color) = 9 points. So, the correct Apgar score for this newborn is 9.
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