A nurse is orienting a newly licensed nurse in the care of an infant who has myelomeningocele.
Which of the following actions by the new nurse indicates the teaching has been effective?
Takes an axillary temperature.
Places the infant in a side-lying position.
Maintains a dry dressing over the sac.
Performs range of motion on the infant's hips.
The Correct Answer is A
A. Infants with spina bifida, including those with myelomeningocele, have an increased risk of rectal anomalies, so avoiding rectal temperatures is essential. The correct and safe method of temperature measurement for these infants is typically axillary.
B. Placing the infant in a side-lying position is not recommended for a child with myelomeningocele. The preferred position is prone to avoid pressure on the sac and reduce the risk of rupture and infection.
C. Maintains a dry dressing over the sac: While the sac should be kept covered, it is typically kept moist with sterile saline-soaked gauze to prevent it from drying out and to minimize the risk of infection.
D. Performs range of motion on the infant's hips: Range of motion exercises might be indicated later on, but initially, the focus is on protecting the sac and preventing complications.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Individuals with spina bifida who are paralyzed from the waist down may have difficulty emptying their bladder completely and may need to perform intermittent catheterization.
The frequency of catheterization can vary depending on the individual’s needs, but it is typically performed every 3-6 hours or 4-6 times per day.
Choice A, “I do wheelchair exercises while watching TV,” is a positive statement because exercise is important for overall health and well-being.
Choice B, “I carry a water bottle with me because I drink a lot of water,” is also a positive statement because staying hydrated is important for overall health.
Choice C, “I use a suppository every night to have a bowel movement,” is not necessarily an indication for further teaching because some individuals with spinal bifida may need to use bowel management techniques such as suppositories to help regulate bowel movements.
Correct Answer is A
Explanation
Chronic glomerulonephritis is a condition that causes inflammation of the glomeruli, which are tiny filtering units in the kidneys.
This can lead to poor kidney function and an increase in waste products in the bloodstream.
Blood urea nitrogen (BUN) is a waste product that is normally filtered by the kidneys and excreted in urine.
A BUN level of 50 mg/dL is higher than the normal range, indicating poor kidney function.
Choice B is incorrect because a serum phosphorus level of 4.0 mg/dL is within
the normal range for adults.
Choice C is incorrect because a serum potassium level of.8 mEq/L is within the normal range for adults.
Choice D is incorrect because proteinuria (the presence of protein in urine) is a
common finding in glomerulonephritis.
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