An infant has undergone surgical repair of her myelomeningocele and is returned to the pediatric unit. Her mother tearfully says to the nurse, "I wish I could hold my baby.”. Which nursing action would be most appropriate?

Explore with the mother why she wants to hold the baby at this time.

Show the mother how to lightly rub the baby's back above the suture line.

Help the mother hold the baby without placing pressure on the suture line.

Reassure the mother that she will be able to hold her baby in four to five days.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Exploring why the mother wants to hold the baby is important, but it does not directly address her immediate desire to hold her baby. Delaying the action could lead to emotional distress for the mother.

Choice B rationale:

Showing the mother how to lightly rub the baby's back above the suture line might be appropriate, but it doesn't fulfill the mother's wish to hold her baby. It also doesn't fully consider the sensitivity of the surgical site.

Choice C rationale:

Helping the mother hold the baby without placing pressure on the suture line is the most appropriate action. It addresses the mother's emotional needs while also considering the infant's post-operative condition.

Choice D rationale:

Reassuring the mother that she will be able to hold her baby in four to five days does not provide immediate comfort and support for her emotional distress. It's important to address her needs in the present moment.

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Correct Answer is A

Explanation

An hour before meals and at bedtime.

Choice A rationale:

Scheduling chest physiotherapy an hour before meals and at bedtime is optimal. This timing helps prevent aspiration during meals and aids in clearing secretions before sleep. It complements the patient's meal schedule and sleep routine.

Choice B rationale:

Every six hours around the clock could disrupt the patient's sleep and meal times. Chest physiotherapy might not align well with the patient's daily activities, potentially affecting treatment compliance and effectiveness.

Choice C rationale:

Performing chest physiotherapy upon awakening and after meals might increase the risk of aspiration during meals. Clearing airways before meals is safer, and performing it right after meals could cause discomfort.

Choice D rationale:

Evenly spaced physiotherapy when awake lacks synchronization with meal and sleep times. This approach might not optimize treatment effects and patient convenience.

A. BUN 14 mg/dL. B. Serum Creatinine 0.4 mg/dL. C. Urine output 76 mL/24 hours. D. Hbg 12 g/dL.

Correct Answer is C

Explanation

Urine output 76 mL/24 hours.

Choice A rationale:

BUN (Blood Urea Nitrogen) of 14 mg/dL falls within the normal range (7-20 mg/dL) and is not an immediate concern.

Choice B rationale:

Serum Creatinine of 0.4 mg/dL is also within the normal range (0.2-0.5 mg/dL) and does not warrant immediate action.

Choice C rationale:

Urine output of 76 mL/24 hours is significantly decreased from the expected normal range (1-2 mL/kg/hour), indicating potential kidney dysfunction or dehydration. This requires immediate action to assess the child's hydration status and kidney function.

Choice D rationale:

Hb (Hemoglobin) of 12 g/dL is within the normal range for a 5-year-old child (11.5-15.5 g/dL) and does not necessitate urgent intervention.

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An infant has undergone surgical repair of her myelomeningocele and is returned to the pediatric unit. Her mother tearfully says to the nurse, "I wish I could hold my baby.”. Which nursing action would be most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 4-year-old child with a history of cystic fibrosis is hospitalized with an acute pulmonary exacerbation. His prescription includes chest physiotherapy four times a day, antibiotics via IV, and pancreatic enzymes. Which time is best for the nurse to plan for chest physiotherapy?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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