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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?

A.

Apply snug, clean diapers.

B.

Obtain rectal temperatures.

C.

Place the newborn in the prone position.

D.

Cover the lesion with a dry dressing.

Answer and Explanation

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 A

Explanation

A. Uterine atony is the most common cause of postpartum hemorrhage and is more likely to occur after a delivery of a large infant or in cases of rapid or prolonged labor.
B. Thrombophlebitis is a risk after childbirth, especially in clients who have undergone cesarean delivery or who have other risk factors such as prolonged immobility, but it is not directly related to the size of the newborn.
C. Puerperal infection is a risk following childbirth, but it is not directly related to the size of the newborn.
D. Retained placental fragments can lead to postpartum hemorrhage, but the size of the newborn is not a direct risk factor for this complication.

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.

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