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 D
Explanation
Choice A reason: Rhinorrhea, or a runny nose, is a common symptom of RSV and, while it should be monitored, it is not typically an urgent concern that requires immediate reporting to a provider.
Choice B reason: Pharyngitis, or a sore throat, is another symptom that can be associated with RSV. Like rhinorrhea, it should be monitored but does not usually necessitate immediate reporting.
Choice C reason: Coughing is a typical symptom of RSV and is expected. It should be monitored for changes in character or severity but is not generally an urgent concern for immediate reporting.
Choice D reason: Tachypnea, or rapid breathing, is a sign of respiratory distress and is a critical finding in an infant with RSV. It indicates that the infant's ability to breathe effectively is compromised and requires immediate attention from a healthcare provider.
Correct Answer is B
Explanation
Choice A reason: Assessing vital signs every 4 hours is important, but it is not specific to the care of an infant post-cardiac catheterization. Vital signs should be monitored according to the infant's condition and hospital policy.
Choice B reason: Monitoring the color of the affected extremity is crucial after cardiac catheterization to ensure there is no compromise in blood flow, which could indicate a vascular injury or thrombosis at the catheterization site.
Choice C reason: Maintaining NPO (nothing by mouth) status for 8 hours may be necessary before the procedure, but post-catheterization care typically includes gradual reintroduction of fluids and then food as tolerated.
Choice D reason: Keeping the affected extremity flexed is not recommended post-cardiac catheterization. The limb should be kept straight to avoid bending at the catheterization site, which could lead to bleeding or clot formation.
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