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
Related Questions
Correct Answer is B
Explanation
Behavioral approaches have the most evidence for treating symptoms of Autism
Spectrum Disorder (ASD)1.
Applied Behavior Analysis (ABA) is a notable behavioral treatment for people with ASD that encourages desired behaviors and discourages undesired behaviors to improve a variety of skills.
A reward system for positive behavior is an example of an ABA technique.
Choice A is not correct because allowing for imaginative play with peers without supervision is not a recommended intervention for a child with ASD.
Choice C is not correct because providing a flexible schedule that adjusts to the child’s interests is not a recommended intervention for a child with ASD.
Choice D is not correct because allowing for adjustment of rules to correlate with the child’s behavior is not a recommended intervention for a child with ASD.
Correct Answer is D
Explanation
Hydroceles are common in newborns and often go away without treatment by age.
Choice A is not correct because a hydrocele is not a genetic condition and does not require genetic counseling.
Choice B is not correct because retracting the foreskin and cleansing it several times daily is not necessary for a hydrocele.
Choice C is not correct because surgery is not always necessary for a hydrocele; it often goes away on its own.
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