The nurse is instructing the parents of a child who underwent a surgical repair of a myelomeningocele on how to change an occlusive dressing on the child’s back.
Which parental statement indicates understanding of the procedure?
The skin incision should be kept moist by periodically wetting the dressing.
When changing the dressing, the tape should be removed rapidly from the edges.
The incision should be protected from fecal contamination by an intact dressing.
To ensure easy removal of the sutures, the dressing should be kept dry.
To ensure easy removal of the sutures, the dressing should be kept dry.
The Correct Answer is C
Choice A rationale
Keeping the skin incision moist by periodically wetting the dressing is not the recommended care for a myelomeningocele surgical repair. The dressing needs to be kept dry to prevent infection and promote healing.
Choice B rationale
Removing the tape rapidly from the edges of the dressing during a change is not advised. This could potentially damage the skin and disrupt the healing process.
Choice C rationale
An intact dressing protects the incision from fecal contamination, which is crucial in preventing infection. This statement indicates an understanding of the procedure.
Choice D rationale
While it’s important to keep the dressing dry to ensure easy removal of sutures, it’s not the primary concern. The main goal is to protect the incision from contamination.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Immunocompromised children are generally not given live virus vaccines due to the risk of developing the disease the vaccine is meant to prevent.
Choice B rationale
This is the correct statement. If a child has a fever or is ill, vaccination may be postponed.
Choice C rationale
Second doses of vaccines are generally not given to children who have had allergic reactions to the first dose.
Choice D rationale
Breastfeeding does not interfere with the effectiveness of vaccines. In fact, breastfeeding can enhance the response to certain vaccine antigens.
Correct Answer is D
Explanation
Choice A rationale
Placing a pulse oximeter on the heel of a newborn can help monitor oxygen saturation levels. However, the symptoms described, such as jitteriness, hypotonicity, and a weak cry, are more indicative of hypoglycemia, a condition that would not be detected by a pulse oximeter.
Choice B rationale
Swaddling the infant in a warm blanket can help maintain body temperature, but it does not address the underlying cause of the symptoms, which are suggestive of hypoglycemia.
Choice C rationale
Documenting the findings in the record is an important part of nursing care, but it does not provide immediate intervention for the symptoms observed.
Choice D rationale
Obtaining a heel stick blood glucose level is the appropriate action given the symptoms described. Jitteriness, hypotonicity, and a weak cry can be signs of neonatal hypoglycemia. Prompt diagnosis and treatment are essential to prevent potential complications.
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