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

The newborn should be placed in prone position to prevent pressure to the lesion which may lead to damage to the contents of the sac. It should be covered with a sterile, wet gauze to maintain the integrity of the sac.

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Correct Answer is B

Explanation

A. This response does not respect the client's autonomy and right to confidentiality.

B. This response acknowledges the client's feelings and opens up the opportunity for further discussion.
C. While it's important for parents to be informed about their child's health condition, especially if the adolescent is a minor, this response may escalate the client's anxiety and fear about disclosing their infection to their parents.
D. This response minimizes the client's concerns and may not accurately reflect the complexity of their situation.

A. Provide age-appropriate stimulation. B. Educate the parents about the defect. C. Maintain the integrity of the sac. D. Promote maternal-infant bonding.

Correct Answer is C

Explanation

The priority nursing goal is to maintain the integrity of the sac.

Myelomeningocele is a type of spina bifida where the spinal cord and its covering (meninges) protrude through an opening in the vertebrae, forming a sac on the baby's back. It is crucial to protect this sac from injury and infection to prevent complications such as meningitis and nerve damage.

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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?

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Correct Answer is B

Explanation

A nurse is caring for a newborn who has myelomeningocele. Which of the following nursing goals has the priority in the care of this infant?

Correct Answer is C

Explanation

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