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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Massaging the fundus is the first-line intervention when the fundus is soft and spongy, indicating uterine atony. Massage stimulates uterine contractions, reducing postpartum bleeding and restoring uterine tone, which is crucial to prevent hemorrhage.
Choice B rationale
Notifying the healthcare provider is necessary if initial interventions fail to address uterine atony. However, immediate action such as massaging the fundus should be taken first to minimize bleeding risks and stabilize the client.
Choice C rationale
Documenting fundal height and consistency is important but not an immediate intervention. Recording observations without addressing the atony fails to prevent potential complications like postpartum hemorrhage, which requires prompt and active management.
Choice D rationale
Administering Oxytocin as per MD orders aids uterine contraction but is not the first intervention. Massaging the fundus provides immediate mechanical stimulation to contract the uterus, a vital step before pharmacological measures are considered.
Correct Answer is D
Explanation
Choice A rationale
Liver function tests, while important for identifying hepatic disorders, are not directly associated with polycystic ovarian syndrome (PCOS). PCOS is primarily an endocrine disorder affecting reproductive hormones, not liver function.
Choice B rationale
Blood urea nitrogen (BUN) is used to assess renal function but is not typically relevant for PCOS. PCOS does not inherently affect kidney function, making this test unnecessary in routine monitoring for this condition.
Choice C rationale
Thyroid-stimulating hormone levels are assessed to rule out thyroid dysfunction, which can present with similar symptoms to PCOS. However, thyroid issues are not caused by PCOS and monitoring TSH is not central to PCOS management.
Choice D rationale
Serum glucose levels are critical in PCOS management due to the increased risk of insulin resistance and type 2 diabetes. Monitoring these levels helps to manage glucose metabolism and prevent complications, making it a key parameter in care for PCOS patients.
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