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 D
Explanation
A. Administering oxytocic medication may be necessary to stimulate uterine contractions and control bleeding, but palpating the client's uterine fundus is the priority to assess for uterine atony or excessive bleeding.
B. Increasing the client's fluid intake is important for hydration but does not address the immediate concern of potential postpartum hemorrhage.
C. Assisting the client on a bedpan to urinate is important for comfort and bladder emptying but does not address the priority of assessing and managing postpartum bleeding.
D. Palpating the client's uterine fundus is the priority nursing intervention to assess for uterine atony or excessive bleeding, which could indicate postpartum hemorrhage.
Correct Answer is A
Explanation
A. Encouraging the client to move to the left lateral position helps to promote uterine
contractions and reposition the uterus to its midline position, which can help to alleviate uterine atony.
B. Assisting the client to the bathroom to void may be appropriate to relieve bladder distention, but it does not directly address the issue of uterine atony.
C. Asking the client to rate her pain is not relevant to the assessment findings of a slightly boggy and displaced fundus.
D. Encouraging the client to perform Kegel exercises is not indicated for the management of uterine atony.
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