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. 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.
Correct Answer is B
Explanation
A. An apical heart rate of 130/min is within the normal range for a newborn and does not require further assessment by the provider.
B. Documenting this as an expected finding is appropriate as the normal range for a newborn's heart rate is typically between 120-160 beats per minute.
C. Asking another nurse to verify the heart rate may delay care unnecessarily, as the rate is within the expected range.
D. There is no indication to prepare the newborn for transport to the NICU based solely on an apical heart rate of 130/min, as this is within the normal range.
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