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 A
Explanation
The nurse should place the client on a low-sodium, fluid-restricted diet.
Acute glomerulonephritis is a kidney disease that can cause fluid retention and edema.
A low-sodium diet can help reduce fluid retention and swelling.
Fluid restriction can also help manage fluid balance and prevent further complications.
Choice B is not the best answer because a regular diet with no added salt may still contain high levels of sodium.
Choice C is not the best answer because a low-protein, low-potassium diet may not address the client’s fluid retention and edema.
Choice D is not the best answer because a low-carbohydrate, low-protein diet may not provide adequate nutrition for the client.
Correct Answer is B
Explanation
The correct answer is choiceb. Firmly attached white particles on the hair.
Choice A rationale:
Itching and scratching of the head are common symptoms of pediculosis capitis, but they are not definitive indicators. Itching can be caused by various other conditions such as dandruff or allergies.
Choice B rationale:
Firmly attached white particles on the hair, known as nits, are a definitive sign of pediculosis capitis.Nits are lice eggs that stick to the hair shafts and are difficult to remove.
Choice C rationale:
Thick yellow crusted lesions on a red base are more indicative of impetigo, a bacterial skin infection, rather than pediculosis capitis.
Choice D rationale:
Patchy areas of hair loss are typically associated with conditions like alopecia areata or fungal infections such as tinea capitis, not pediculosis capitis.
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