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.
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Related Questions
Correct Answer is C
Explanation
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.
Correct Answer is A
Explanation
Choice A rationale
Deep tendon reflexes of +1 are not consistent with preeclampsia. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of kidney damage. One of the symptoms can be hyperreflexia, or overly active reflexes, not diminished reflexes.
Choice B rationale
Blood pressure of 148/98 mm Hg is consistent with preeclampsia, as one of the defining features of preeclampsia is high blood pressure.
Choice C rationale
1+ pitting sacral edema is consistent with preeclampsia. Edema, or swelling, is a common symptom of preeclampsia.
Choice D rationale
3+ protein in the urine is consistent with preeclampsia. One of the defining features of preeclampsia is the presence of excess protein in urine (proteinuria), which indicates kidney problems. Deep vein thrombosis Deep vein thrombosis Explore
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