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.

Answer and Explanation

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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Correct Answer is D

Explanation

Choice A rationale
Obtaining blood cultures is not the first action to take in this situation. Blood cultures would be used to identify a bloodstream infection, which is not indicated by the client’s current symptoms.
Choice B rationale
Covering the lesion with a dressing is not the appropriate action. Herpes lesions are highly contagious, and covering them does not eliminate the risk of transmission during vaginal delivery.
Choice C rationale
Administering penicillin is not the appropriate action. Penicillin is an antibiotic used to treat bacterial infections, not viral infections like herpes.
Choice D rationale
Preparing for a cesarean section is the correct action. A cesarean section is recommended for women with active genital herpes lesions or prodromal symptoms at the time of labor to prevent transmission of the virus to the newborn during delivery.

A. To prevent herpes infection B. To prevent eye infections C. To clear the infant’s vision D. To dilate the pupil so the red reflex can be visualized E. To dilate the pupil so the red reflex can be viWhat would be the correct response from the nurse regarding the purpose of the ointment?

Correct Answer is B

Explanation

Choice A rationale
While it is true that the ointment can help prevent certain types of infections, it is not specifically intended to prevent herpes infection. Herpes is a viral infection, and the ointment is an antibiotic, which is used to prevent bacterial infections.
Choice B rationale
The primary purpose of eye ointment is to protect newborns from serious eye infections caused by common bacteria. Mothers who have a sexually transmitted infection (STI) can pass it to their newborns during childbirth, putting them at risk for an eye infection known as ophthalmia neonatorum (ON)3.
Choice C rationale
The ointment does not serve to clear the infant’s vision. It is applied to the eyes to prevent bacterial infections, not to improve or alter the infant’s vision.
Choice D rationale
The ointment is not used to dilate the pupil to visualize the red reflex. The red reflex is a reflection from the lining of the eye that is often observed when looking at the pupil, but this is not related to the application of the ointment.

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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?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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Naxlex Comprehensive Predictor Exams

A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. What action should the nurse take?

Correct Answer is D

Explanation

A father observing his newborn’s admission to the nursery notices that eye ointment is applied to the infant’s eyes. He asks the nurse about the purpose of the ointment. What would be the correct response from the nurse regarding the purpose of the ointment?

Correct Answer is B

Explanation

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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?