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
If a client reports feeling down and sad, having no energy, and wanting to cry, the nurse’s priority action should be to ask the client if she has considered harming her newborn. This is because these symptoms may indicate postpartum depression, a serious condition that can lead to harm to both the mother and the baby if left untreated.
Choice B rationale
While reinforcing postpartum and newborn care discharge teaching is important, it is not the priority action in this situation. The client’s emotional health needs to be addressed first.
Choice C rationale
Assisting the family to identify prior use of positive coping skills in family crises can be helpful, but it is not the priority action in this situation. The client’s immediate emotional health needs to be addressed first.
Choice D rationale
Anticipating a prescription by the provider for an antidepressant may be part of the treatment plan for this client, but it is not the priority action. The nurse first needs to assess the safety of the client and her newborn.
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.
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