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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
Prednisone is a type of steroid medicine that helps decrease severe inflammation and is usually given for a short time while other medicines are started that can take longer to be effective.
Choice A is not an answer because there is no information available that suggests taking a 45-minute nap daily would be beneficial for a child with juvenile idiopathic arthritis.
Choice C is not an answer because it may not be necessary for the child to stay at home on days when their joints are painful.
Choice D is not an answer because applying cool compresses for 20 minutes every hour may not be the most effective way to manage pain and inflammation.
Correct Answer is B
Explanation
This is an important measure to prevent the spreading of impetigo to others and to other parts of the body, as the bacteria can survive on clothing and other objects12.
Choice A.
Keeping the child on droplet precautions at home is incorrect, as impetigo is not spread by respiratory droplets, but by direct contact with the sores or contaminated items.
Choice C.
Immunizing household contacts for the disease is incorrect, as there is no vaccine for impetigo, which is caused by different types of bacteria.
Choice D.
Giving the child a chlorine bath twice daily is incorrect, as chlorine can irritate the skin and worsen impetigo.
The recommended treatment is to wash the sores with soap and water and
apply antibiotic ointment or cream23.
Therefore, choice B is the best answer to this question.
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