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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Providing frequent range of motion to the neck and shoulders is not recommended for an infant with bacterial meningitis, as it could cause discomfort or pain due to the inflammation of the meninges.
Choice B reason: Keeping the television on to provide background noise is not advisable, as infants with meningitis may be sensitive to noise, and it could potentially increase their discomfort or agitation.
Choice C reason: Padding the siderails of the crib is important to ensure the safety of the infant. It helps to prevent injury if the infant has seizures, which can be a complication of meningitis.
Choice D reason: Placing the infant in a semi-private room is not a specific intervention for the care of an infant with bacterial meningitis. It is more important to focus on interventions that address the infant's immediate health needs.
Correct Answer is B
Explanation
Choice A reason: Teaching the child about cast care is important, but it is not the first action to take. Education on cast maintenance and activity restrictions will follow after addressing immediate needs.
Choice B reason: Administering pain medication should be the first action taken by the nurse. After a cast application for a fracture, the child is likely experiencing pain, and managing this pain is a priority to ensure comfort and facilitate healing.
Choice C reason: Elevating the child's leg is a subsequent action that can help reduce swelling and discomfort, but it is not the first action to take. Pain management is the priority before positioning.
Choice D reason: Petaling the edges of the cast, which involves placing soft material around the rough edges to prevent skin irritation, is important but not the first action. The initial focus should be on pain relief.
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