A nurse is providing discharge teaching to the guardian of an infant who had a large myelomeningocele repair in the lumbar area. Which of the following instructions should the nurse include?

Perform clean intermittent catheterization every 8 hours.

Use a rectal thermometer to stimulate the passage of stool twice per day.

Anticipate gradual loss of function in the lower extremities.

Check toys and pacifiers for the presence of latex.

Answer and Explanation

The Correct Answer is D

Choice A reason: This is not the correct instruction to include in the discharge teaching. Perform clean intermittent catheterization every 8 hours is a possible intervention for infants who have neurogenic bladder dysfunction due to spinal cord injury or spina bifida. However, not all infants who have myelomeningocele repair require catheterization. The nurse should assess the infant’s bladder function and teach the guardian how to perform catheterization if needed.

Choice B reason: This is not the correct instruction to include in the discharge teaching. Use a rectal thermometer to stimulate the passage of stool twice per day is a possible intervention for infants who have neurogenic bowel dysfunction due to spinal cord injury or spina bifida. However, not all infants who have myelomeningocele repair require rectal stimulation. The nurse should assess the infant’s bowel function and teach the guardian how to manage constipation or fecal incontinence if needed.

Choice C reason: This is not the correct instruction to include in the discharge teaching. Anticipate gradual loss of function in the lower extremities is a possible outcome for infants who have myelomeningocele repair, depending on the location and severity of the defect. However, the nurse should not assume that the infant will lose function in the lower extremities. The nurse should monitor the infant’s motor and sensory development and provide appropriate interventions to promote mobility and prevent complications.

Choice D reason: This is the correct instruction to include in the discharge teaching. Check toys and pacifiers for the presence of latex is an important precaution for infants who have myelomeningocele repair, as they are at risk of developing latex allergy due to repeated exposure to latex products during surgery and medical procedures. The nurse should teach the guardian how to identify and avoid latex-containing items and how to recognize and treat signs of allergic reaction.

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Correct Answer is ["A","C","D"]

Explanation

Choice A reason: Recommending the use of a wheelchair can help prevent stress on the lower extremities, which is important for an adolescent with muscular dystrophy. This condition can lead to muscle weakness and using a wheelchair can aid in mobility and independence.

Choice B reason: Avoiding influenza and pneumococcal vaccines is not recommended. Vaccinations are important for preventing infections, especially in individuals with compromised health conditions like muscular dystrophy.

Choice C reason: Initiating a referral for chest physiotherapy every 4 hours can be beneficial for an adolescent with muscular dystrophy. This therapy can help clear mucus from the lungs and improve respiratory function, which is often compromised in this condition.

Choice D reason: Encouraging the adolescent to perform incentive spirometry is important to maintain lung capacity. Muscular dystrophy can affect the muscles used for breathing, and incentive spirometry can help strengthen these muscles and improve respiratory health.

A. BP 150/90 mmHg B. BUN 20 mg/dL C. Urine protein 12 mg/dL D. 2+ pedal edema

Correct Answer is A

Explanation

Choice A reason: A blood pressure reading of 150/90 mmHg is significantly high for a 7-year-old child and indicates hypertension, which can be a serious complication of acute glomerulonephritis. It is a priority to report this finding to the provider as it may require immediate intervention.

Choice B reason: A BUN level of 20 mg/dL is within the normal range for children and is not typically a cause for immediate concern. However, it should be monitored along with other kidney function tests.

Choice C reason: Urine protein of 12 mg/dL is a common finding in acute glomerulonephritis due to increased permeability of the glomerular membrane. It is important but not as urgent as the blood pressure finding.

Choice D reason: 2+ pedal edema is a sign of fluid retention, which is expected in acute glomerulonephritis. While it should be addressed, it is not as immediately concerning as severe hypertension.

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A nurse is providing discharge teaching to the guardian of an infant who had a large myelomeningocele repair in the lumbar area. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is creating a plan of care for an adolescent who has muscular dystrophy. Which of the following interventions should the nurse include in the plan?

Correct Answer is ["A","C","D"]

Explanation

A nurse is caring for a 7-year-old child who has acute glomerulonephritis. Which of the following findings is the priority for the nurse to report to the provider?

Correct Answer is A

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