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 .

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

Chorioamnionitis. Based on the information provided, the patient is at risk of developing chorioamnionitis, which is an infection of the membranes surrounding the fetus.

Choice B rationale

Preeclampsia. There is no information provided that would indicate the patient is at risk of developing preeclampsia.

Choice C rationale

Gestational diabetes. There is no information provided that would indicate the patient is at risk of developing gestational diabetes.

Choice D rationale

Preterm labor. There is no information provided that would indicate the patient is at risk of developing preterm labor.

A. Perinatal asphyxia. B. Preterm delivery. C. Fetal hyperinsulinemia. D. Placental insufficiency.

Correct Answer is D

Explanation

Choice A rationale

Perinatal asphyxia refers to a lack of oxygen flow to the fetus around the time of birth. This can lead to multiple organ dysfunction and neurological issues, but it is not a common cause of a newborn being small for gestational age.

Choice B rationale

Preterm delivery can result in a newborn being small for their gestational age simply because they have not had the full amount of time to grow in the womb. However, preterm babies are typically compared to other preterm babies when assessing size, not to full-term babies.

Choice C rationale

Fetal hyperinsulinemia, or an excess of insulin in the fetus, can lead to excessive growth and a larger-than-average baby size (macrosomia), not a smaller size.

Choice D rationale

Placental insufficiency, where the placenta does not work as well as it should, can limit the amount of oxygen and nutrients the fetus receives. This can restrict the baby’s growth, leading to a small size for gestational age.

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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?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

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Correct Answer is A

Explanation

Choice B rationale

Choice C rationale

Choice D rationale

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Choice A rationale

Choice B rationale

Choice C rationale

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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?