A nurse is planning care for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac. Which of the following interventions should the nurse include in the plan of care?
Limit visitors to immediate family members.
Maintain the infant in the supine position.
Provide a latex-free environment.
Initiate contact precautions.
The Correct Answer is C
Infants with spina bifida are at an increased risk of developing a latex allergy
due to repeated exposure to latex products during medical procedures.
Providing a latex-free environment can help prevent the development of an allergy.
Choice A is not correct because limiting visitors to immediate family members is not necessary for the care of an infant undergoing surgical closure of the myelomeningocele sac.
Choice B is not correct because maintaining the infant in the supine position is not necessary for this procedure.
Choice D is not correct because initiating contact precautions is not necessary for this procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
According to the CDC, one of the individual risk factors for suicide is a previous suicide attempt.
Choice A is not the answer because while substance abuse is a risk factor for suicide, it is not the priority risk factor for suicide completion in this case.
Choice C is not the answer because while loss of relationships can contribute to
suicide risk, it is not the priority risk factor for suicide completion in this case.
Choice D is not the answer because while a history of mental illness is a risk factor for suicide, it is not the priority risk factor for suicide completion in this case.
Correct Answer is ["C","D","E"]
Explanation
The correct answers are C, D, and E.
Choice A rationale: Intact epidermis would not be expected with a partial-thickness burn as the burn extends into the dermis.
Choice B rationale: A dry surface is not characteristic of partial-thickness burns, which typically have a moist surface.
Choice C rationale: Partial-thickness burns are sensitive to touch due to the damage to nerve endings in the dermis.
Choice D rationale: Wound blanches with pressure because the blood vessels are damaged, allowing blanching on pressure.
Choice E rationale: Blisters are a common feature of partial-thickness burns, as the damage to the dermis causes fluid to accumulate.
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