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.
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Related Questions
Correct Answer is B
Explanation
A. Initiating early feeding helps promote the passage of meconium, which contains bilirubin, out of the newborn's body, reducing the risk of jaundice.
B. Preparing for an exchange blood transfusion is not appropriate for preventing jaundice at this stage. Exchange transfusion is a treatment option for severe hyperbilirubinemia that has not
responded to other measures.
C. Suctioning excess mucus with a bulb syringe is important for maintaining a patent airway in the newborn but does not directly prevent jaundice.
D. Beginning phototherapy is a treatment for jaundice once it has occurred but is not a preventive measure.
Correct Answer is B
Explanation
A. Using a suction catheter is appropriate but may not be the quickest method for immediate airway clearance in this situation.
B. Suctioning the mouth with a bulb syringe is the priority action as it helps clear the airway of secretions and prevents aspiration, ensuring the newborn can breathe effectively.
C. Turning the newborn on his side can help with drainage but does not actively clear the airway, making it a less immediate priority.
D. Suctioning the nose is important, but the mouth should be cleared first to ensure a patent airway, making this option secondary.
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