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.

Answer and Explanation

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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Correct Answer is A

Explanation

Isotretinoin has been associated with depression and other psychiatric side eﬀects.
The client should report any changes in mood or behavior, including feelings of isolation, to the provider immediately.
Choice B is not an answer because while frequent nosebleeds can be a side
eﬀect of isotretinoin, it is not the priority to report to the provider.
Choice C is not an answer because while back pain can be a side eﬀect of isotretinoin, it is not the priority to report to the provider.
Choice D is not an answer because while itching of the skin can be a side eﬀect of isotretinoin, it is not the priority to report to the provider.

A. Improve the client's communication skills. B. Provide respite services for the parents. C. Foster self-care activities. D. Modify the environment.

Correct Answer is D

Explanation

The correct answer is d. Modify the environment.

Rationale for each choice:

Choice a. Improve the client's communication skills.

Statement:While communication is important,it is not the priority for a child with hemiplegic cerebral palsy.
Rationale:Hemiplegic cerebral palsy primarily affects motor skills,not communication abilities.While some children with hemiplegic cerebral palsy may have speech difficulties,it is not the most pressing concern in this case.Addressing environmental barriers to promote mobility and independence takes precedence.

Choice b. Provide respite services for the parents.

Statement:Respite services can provide valuable support for parents,but they are not the priority in this case.
Rationale:The focus of the care plan should be on the child's immediate needs and safety.Modifying the environment to enhance the child's functional abilities is crucial for their development and well-being.

Choice c. Foster self-care activities.

Statement:Encouraging self-care is essential,but it requires a supportive environment.
Rationale:Before promoting self-care activities,the nurse must ensure the child has the necessary accommodations and modifications in place to facilitate independence.

Choice d. Modify the environment.

Statement:This is the priority goal for a child with hemiplegic cerebral palsy.
Rationale:Modifying the home environment can significantly improve the child's mobility,safety,and ability to participate in daily activities.Examples of modifications include:
- Installing grab bars in the bathroom
- Widening doorways
- Removing tripping hazards
- Providing adaptive equipment such as special chairs or utensils
- Ensuring adequatelighting

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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?

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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?