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 B
Explanation
A. Covering the cord with the diaper can increase moisture around the stump, leading to delayed cord separation and potential infection.
B. Giving a sponge bath until the cord stump falls off helps to keep the area clean and dry, reducing the risk of infection.
C. Washing the cord daily with mild soap and water is not recommended as it can increase the risk of infection and delay cord separation.
D. Applying petroleum jelly to the cord stump is not recommended as it can trap moisture and increase the risk of infection.
Correct Answer is D
Explanation
A. Preterm delivery may result in a newborn being small for gestational age, but it is not the primary cause of this condition.
B. Fetal hyperinsulinemia may contribute to macrosomia (large for gestational age) rather than small for gestational age.
C. Perinatal asphyxia may lead to intrauterine growth restriction but is not a primary cause of being small for gestational age.
D. Placental insufficiency is a common cause of intrauterine growth restriction and results in inadequate nutrient and oxygen delivery to the fetus, leading to a newborn being small for gestational age.
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