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.

Answer and Explanation

The Correct Answer is C

A.   While keeping the newborn clean and dry is important for overall hygiene, in the case of spina bifida, applying snug diapers might cause pressure on the lesion. Therefore, this action could potentially harm the newborn.

B.   Obtaining rectal temperatures is contraindicated in newborns with spina bifida because it can introduce bacteria into the spinal defect, increasing the risk of infection.
C.   Placing the newborn in the prone position helps to minimize pressure on the spinal lesion and reduce the risk of trauma. It also promotes proper spinal alignment and comfort for the newborn.
D.   Covering the lesion with a dry dressing is not recommended because it can trap moisture and increase the risk of infection.

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Correct Answer is A

Explanation

A. Changing the perineal pad is a task that can be safely delegated to an assistive personnel (AP) as it involves basic hygiene care and does not require nursing judgment.
B. Observing an area of redness on the breast may require nursing assessment and judgment to determine if further intervention is needed.
C. Monitoring vital signs during admission of a client with gestational hypertension requires nursing assessment and judgment to detect any signs of worsening condition or complications.
D. Providing a sitz bath to a client with a fourth-degree laceration requires nursing assessment and judgment to ensure appropriate wound care and pain management.

A. Educate the parents about the defect. B. Maintain the integrity of the sac. C. Provide age-appropriate stimulation. D. Promote maternal-infant bonding.

Correct Answer is B

Explanation

A. Educating the parents about the defect is important for their understanding and involvement in the care of the newborn, but it is not the priority when the infant has a myelomeningocele.
B. Maintaining the integrity of the sac is the priority goal in the care of a newborn with myelomeningocele to prevent infection and protect the exposed neural tissue.

C. Providing age-appropriate stimulation is important for the overall development of the newborn but is not the priority when the infant has a myelomeningocele.
D. Promoting maternal-infant bonding is essential for the emotional well-being of both the
mother and the newborn, but it is not the priority when immediate physical care needs exist, such as maintaining the integrity of the sac.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

Correct Answer is A

Explanation

A nurse is caring for a newborn who has myelomeningocele. Which of the following nursing goals has the priority in the care of this infant?

Correct Answer is B

Explanation

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