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 A
Explanation
A.Infants with spina bifida, including those with myelomeningocele, have an increased risk of rectal anomalies, so avoiding rectal temperatures is essential. The correct and safe method of temperature measurement for these infants is typically axillary.
B. Placing the infant in a side-lying positionis not recommended for a child with myelomeningocele. The preferred position isprone to avoid pressure on the sac and reduce the risk of rupture and infection.
C.Maintains a dry dressing over the sac: While the sac should be kept covered, it is typically kept moist with sterile saline-soaked gauze to prevent it from drying out and to minimize the risk of infection.
D.Performs range of motion on the infant's hips: Range of motion exercises might be indicated later on, but initially, the focus is on protecting the sac and preventing complications.
Correct Answer is B
Explanation
Pruritus, or itching, of the scalp, is a common symptom of pediculosis capitis, also known as head lice infestation 123.
Choice A is not correct because dry patches on the scalp are not a common symptom of pediculosis capitis 123.
Choice C is not correct because bald patches on the scalp are not a common symptom of pediculosis capitis 123.
Choice D is not correct because blisters on the scalp are not a common symptom of pediculosis capitis 123.
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