An infant has just undergone surgical repair of a myelomeningocele.
What is the priority nursing intervention to perform immediately following the procedure?

Position the infant supine to protect the surgical site.

Monitor head circumference.

Monitor intake and output.

Maintain skin integrity.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Positioning the infant supine increases pressure on the surgical site, potentially disrupting healing or increasing the risk of cerebrospinal fluid leakage. Supine positioning is contraindicated immediately after myelomeningocele repair as it can compromise the integrity of the repair.

Choice B rationale

Monitoring head circumference detects signs of hydrocephalus, a common complication after myelomeningocele repair due to cerebrospinal fluid dynamics. Enlarging head circumference can indicate increased intracranial pressure and require immediate intervention to prevent further neurological damage.

Choice C rationale

Intake and output monitoring provides essential hydration and renal function data post-surgery. While important, it is not the priority intervention immediately following surgery, as it does not directly address complications such as hydrocephalus or infection risk.

Choice D rationale

Maintaining skin integrity prevents infection and promotes healing but does not address potential neurological complications. While this intervention remains vital for recovery, it is secondary to detecting hydrocephalus or fluid imbalances post-surgery.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale

Keeping the newborn in a well-lit nursery may interfere with their ability to develop circadian rhythms, which are critical for growth and development. Premature newborns are particularly sensitive to environmental stress, and excessive lighting can disrupt their sleep-wake cycle, increasing stress and affecting neurological development.

Choice B rationale

Clustering care activities minimizes disruptions and allows the newborn to have longer periods of rest. This approach is vital for preterm infants, as uninterrupted sleep enhances brain growth, reduces energy expenditure, and promotes physiological stability, such as maintaining appropriate heart and respiratory rates.

Choice C rationale

Using fingertips when calming the newborn may not provide the soothing effects of a whole-hand approach. Gentle hand placement offers a more consistent pressure that mimics the containment provided in the womb, aiding in neuromuscular development and decreasing stress in preterm infants.

Choice D rationale

Positioning the newborn to promote muscle extension opposes the fetal position they naturally adopt and disrupts their physiological flexion posture. This posture facilitates stability and self-regulation and supports motor development, which is essential for preterm infants adjusting to life outside the womb.

A. Mother removes pacifier from the newborn's mouth. B. The newborn is on an every 2-hour feeding schedule. C. Newborn is placed in bassinet on the back. D. Newborn is placed in bassinet with a blanket draped over them.

Correct Answer is C

Explanation

Choice A rationale

Removing a pacifier does not align with preventing SIDS. Studies suggest pacifier use during sleep reduces the risk of SIDS by maintaining airway patency and ensuring better sleep quality, though it should be used appropriately without attaching strings or clips that may pose risks.

Choice B rationale

Feeding every 2 hours does not directly prevent SIDS but supports adequate nutrition for growth and development. While proper feeding schedules are important, specific sleeping arrangements and environment management play a more significant role in reducing SIDS risk.

Choice C rationale

Placing the newborn on their back to sleep aligns with safe sleep recommendations to prevent SIDS. This position reduces the risk of airway obstruction and promotes proper breathing. The supine sleep position is widely endorsed by health organizations for its protective effect.

Choice D rationale

Draping a blanket over the newborn increases the risk of suffocation and overheating, both of which are associated with SIDS. It is essential to keep sleep environments free of loose items and ensure the baby is dressed appropriately for the room's temperature to reduce these risks.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

An infant has just undergone surgical repair of a myelomeningocele.What is the priority nursing intervention to perform immediately following the procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a preterm newborn.Which of the following nursing interventions to promote development should be included in the plan of care?

Correct Answer is B

Explanation

The nurse educates the parents on actions to prevent sudden infant death syndrome.Which observation indicates the teaching has been effective?

Correct Answer is C

Explanation

The following newborns are three-hours old and are sleeping.The registered nurse should notify the provider about which newborn?

The nurse knows that which of the following is not a cause of mastitis?

A 16-year-old is brought to the emergency room by her boyfriend with bruising around her eyes and neck.When asked what happened, she states, "I walked into a door.”. What are the most appropriate interventions by the nurse?

Identify a complication resulting from a cleft palate, the anatomical changes that lead to the complication, and the priority interventions for care.

A nurse is caring for a client who is experiencing menopausal symptoms and asks the nurse about menopausal hormone therapy (HT). The nurse should inform the client that HT is contraindicated due to which of the following findings in the client's medical history?

Which assessment findings would alert the nurse to an infant or child in heart failure?

An 18-hour-old infant with hyperbilirubinemia is placed under phototherapy bank lights.Which of the following is an appropriate intervention for this infant?

A nurse is discussing postpartum depression with a newly licensed nurse.Which of the following statements by the newly licensed nurse indicates an understanding of this condition?

An infant has just undergone surgical repair of a myelomeningocele.
What is the priority nursing intervention to perform immediately following the procedure?