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 D
Explanation
Choice A rationale
While blunt force trauma can cause placental abruption, it is not the most common risk factor. Trauma can lead to abruptio placentae, but this is more likely in cases of severe injury.
Choice B rationale
Cigarette smoking is a risk factor for many pregnancy complications, including placental abruption. However, it is not the most common risk factor.
Choice C rationale
Cocaine use can cause abrupt vasoconstriction and is a risk factor for placental abruption. However, it is not the most common risk factor.
Choice D rationale
Hypertension is the most common risk factor for placental abruption. Chronic hypertension, gestational hypertension, and preeclampsia can all contribute to the risk of developing this condition.
Correct Answer is A
Explanation
Choice A rationale
The nurse’s response, “You seem scared to talk to your parents,” is an empathetic response that validates the client’s feelings and encourages further communication. It’s important for the nurse to provide emotional support and help the client explore her feelings about the situation. The nurse can also provide information about confidentiality laws and discuss potential outcomes of various decisions.
Choice B rationale
Telling the client that her parents will have to be told why she is being admitted may not be accurate depending on the age of the client and local laws regarding minor’s rights to privacy in healthcare. It’s crucial to respect the client’s autonomy and privacy.
Choice C rationale
While it’s possible that the parents might understand, suggesting this puts pressure on the client to disclose her condition to her parents. The nurse should instead focus on supporting the client in making her own decision about disclosure.
Choice D rationale
Offering to tell the parents for the client could undermine the client’s autonomy and may not be legally permissible without the client’s consent. The nurse should instead focus on helping the client explore her options and come to her own decision.
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