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 C
Explanation
A. Monitoring weight is important for assessing growth but may not be the priority for a
newborn who is small for gestational age (SGA) as it doesn't address immediate physiological needs.
B. Monitoring axillary temperature is important for detecting signs of infection or hypothermia, but it's not the priority for a newborn who is small for gestational age (SGA).
C. Monitoring blood glucose levels is the priority for a newborn who is small for gestational age (SGA) because they are at risk for hypoglycemia due to inadequate glycogen stores.
D. Monitoring intake and output is important for overall assessment but is not the priority intervention for a newborn who is small for gestational age (SGA).
Correct Answer is D
Explanation
A) A urine output of 3,000 mL in 12 hours postpartum is typically not concerning. Postpartum diuresis is a normal physiological response as the body eliminates excess fluid accumulated during pregnancy.
B) The fundus palpable at the umbilicus is an expected finding 12 hours postpartum as the uterus begins to contract and return to its pre-pregnancy size.
C) Orthostatic hypotension can occur postpartum as a result of the cardiovascular system adjusting after delivery, but it is not typically a sign of a serious complication.
D) A heart rate of 110/min could indicate a postpartum complication such as hemorrhage or infection and should be investigated further. It is higher than the normal range and could be a sign of an underlying issue that needs immediate attention.
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