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 C

Explanation

Choice A reason: Talking to a toddler about the meaning of death may not be appropriate or helpful, as they may not fully understand the concept. It's important to provide comfort rather than potentially causing confusion or distress.

Choice B reason: While encouraging friends to visit can provide social support, it may not always be feasible or in the best interest of the child's health, especially if the child is very ill or immunocompromised.

Choice C reason: Staying close to the child provides emotional support and comfort, which is crucial during this difficult time. Physical presence and affection can be very reassuring for both the child and the parents.

Choice D reason: Changing the child's schedule every day can be disruptive and may cause additional stress. Consistency and routine can provide a sense of security and stability for a child who is terminally ill.

A. Remove the child's pressure dressing after the first 4 hours. B. Maintain the child's NPO status for 4 to 6 hours. C. Keep the affected extremity straight for at least 6 hours. D. Monitor output using an indwelling urinary catheter for the first 24 hours.

Correct Answer is C

Explanation

Choice A reason: Removing the child's pressure dressing after the first 4 hours is not recommended as it may increase the risk of bleeding. The pressure dressing is typically kept in place longer to ensure hemostasis.

Choice B reason: Maintaining the child's NPO status for 4 to 6 hours post-procedure is a standard practice to prevent nausea and vomiting while anesthesia wears off, but it is not the most critical action in this context.

Choice C reason: Keeping the affected extremity straight for at least 6 hours is essential to prevent bleeding from the catheterization site. This is a critical postoperative care step following arterial cardiac catheterization.

Choice D reason: Monitoring output using an indwelling urinary catheter for the first 24 hours is important for assessing kidney function and fluid balance but is not the immediate priority post-cardiac catheterization.

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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?

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