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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A Covering the umbilical cord stump with the diaper can create a moist environment, which may increase the risk of bacterial growth and infection.
B. Washing the cord stump with soap and water may disrupt the natural drying process and increase the risk of infection
C. Applying petroleum jelly or any other substance to the umbilical cord stump is not necessary and may increase the risk of infection.
Correct Answer is B
Explanation
One of the signs that the bladder may be distended is when the fundus (top of the uterus) is palpable to the right of the midline. This displacement indicates that the bladder is pushing the uterus to the side, which can occur when the bladder is full and obstructing the descent of the uterus into the pelvis during the postpartum period.
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