A nurse is planning care for a newborn who has spinal bifida.
Which of the following actions should be included in the plan of care?
Obtain rectal temperatures
Cover the lesion with a dry dressing
Apply snug clean diapers
Place the newborn in the prone position .
The Correct Answer is D
Choice A rationale
Obtaining rectal temperatures is not recommended for newborns with spinal bifida. This is because the rectal route can introduce bacteria into the body, which can lead to infection.
Additionally, the rectal route may not provide an accurate temperature reading for these newborns.
Choice B rationale
Covering the lesion with a dry dressing is not recommended for newborns with spinal bifida. The lesion should be kept moist to prevent drying and cracking, which can lead to infection.
Choice C rationale
Applying snug clean diapers is not recommended for newborns with spinal bifida. This is because the pressure from the diaper can damage the exposed nerves and tissues in the lesion area.
Choice D rationale
Placing the newborn in the prone position is recommended for newborns with spinal bifida. This position helps to minimize pressure on the lesion and reduces the risk of trauma and infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Regular physical activity plays a key role in managing gestational diabetes. The American College of Obstetricians and Gynecologists (ACOG) recommends aiming for 150 minutes of moderate-level exercise each week during pregnancy. Reducing the exercise schedule to 3 days a week may not provide the recommended amount of physical activity needed to manage gestational diabetes effectively.
Choice B rationale
Glyburide is an oral medication that can be used to manage gestational diabetes when diet and exercise are not enough. It is usually taken before breakfast or the first main meal of the day.
Choice C rationale
This statement is correct. Women who have had gestational diabetes have an increased risk of developing type 2 diabetes later in life.
Choice D rationale
This statement is correct. A diet that includes about 40% to 45% carbohydrates is recommended for managing gestational diabetes.
Correct Answer is D
Explanation
Choice A rationale
Gravida 4 Para 3 at 33 weeks of gestation is not an alarming finding. It simply indicates that the woman is pregnant for the fourth time and has had three previous deliveries. This is a normal part of the woman’s obstetric history and does not need to be reported to the provider.
Choice B rationale
Allergies, such as a sulfa allergy, are important to note in the patient’s medical history. However, unless the patient is being prescribed a medication that she is allergic to, this information does not need to be urgently reported to the provider.
Choice C rationale
A height of 165 cm (66 in), weight of 82 kg (180 lb), and BMI of 30.6 are all within normal ranges for a pregnant woman. These measurements are part of routine prenatal care and do not need to be urgently reported to the provider.
Choice D rationale
A weight gain of 32 kg (7 lb) over the last 2 weeks is concerning. Rapid weight gain can be a sign of preeclampsia, a serious pregnancy complication characterized by high blood pressure. This should be reported to the provider immediately.
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