A nurse is planning care for a newborn who has spina bifida. Which of the following actions should be included in the plan of care?
Apply snug, clean diapers.
Obtain rectal temperatures.
Place the newborn in the prone position.
Cover the lesion with a dry dressing.
The Correct Answer is C
A. Applying snug diapers is not recommended as it can put pressure on the sacral lesion, potentially causing damage or infection.
B. Obtaining rectal temperatures is contraindicated due to the risk of bowel and nerve damage.
C. Placing the newborn in the prone position is the correct action, as it prevents pressure on the lesion and reduces the risk of trauma or infection.
D. Covering the lesion with a dry dressing is incorrect. The lesion should be covered with a moist, sterile, non-adherent dressing to prevent drying out and minimize infection risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Molding refers to the shaping of the fetal head during labor and delivery to facilitate passage through the birth canal. It typically resolves within a few days and does not involve bruising.
B. Caput succedaneum is localized swelling or edema of the scalp that crosses suture lines and typically resolves within a few days. It is not associated with bruising.
C. Pilonidal dimple refers to a small pit or depression in the skin, typically at the base of the spine, and is not related to the finding described.
D. Cephalhematoma is a collection of blood between the skull bone and its periosteum. It is
confined by suture lines and may take weeks to resolve. It does not cross suture lines and may be associated with bruising due to birth trauma.
Correct Answer is C
Explanation
A. Applying snug diapers is not recommended as it can put pressure on the sacral lesion, potentially causing damage or infection.
B. Obtaining rectal temperatures is contraindicated due to the risk of bowel and nerve damage.
C. Placing the newborn in the prone position is the correct action, as it prevents pressure on the lesion and reduces the risk of trauma or infection.
D. Covering the lesion with a dry dressing is incorrect. The lesion should be covered with a moist, sterile, non-adherent dressing to prevent drying out and minimize infection risk.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.