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
Explanation
The correct answer is C. 2 mL/kg/hr.
Choice A rationale: An output of 0.5 mL/kg/hr is insufficient and indicative of ongoing dehydration or inadequate fluid intake.
Choice B rationale: An output of 15 mL/kg/hr is excessive and could suggest overhydration or a different pathology.
Choice C rationale: A urinary output of 2 mL/kg/hr is an ideal measure for indicating that fluid balance has been restored in infants.
Choice D rationale: An output of 7.5 mL/kg/hr is unusually high and not typical for a corrected fluid balance in infants.
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