What is the priority nursing intervention to perform on an infant immediately following repair of a myelomeningocele?

Assess motor function in lower extremities

Maintain skin integrity

Monitor intake and output

Monitor head circumference

Answer and Explanation

The Correct Answer is D

A. Assess motor function in lower extremities: While important for overall neurological assessment, immediate post-repair monitoring of motor function is secondary to monitoring for signs of hydrocephalus (head circumference).
B. Maintain skin integrity: Essential for preventing infection but does not address the immediate post-surgical complication of hydrocephalus.
C. Monitor intake and output: Important for general post-operative care but does not address the immediate concern of monitoring for hydrocephalus.
D. Monitor head circumference: Following repair of a myelomeningocele, infants are at risk for developing hydrocephalus due to abnormal cerebrospinal fluid dynamics. Monitoring head circumference helps detect early signs of increased intracranial pressure, a common complication post-surgery.

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Free Nursing Study Resources

Correct Answer is ["6"]

Explanation

Heart rate (110/min): 2 points

Respiratory effort (slow, weak cry): 1 point

Muscle tone (some flexion of extremities): 1 point

Reflex irritability (grimace): 1 point

Color (body pink, blue extremities): 1 point

APGAR-6

A. O negative blood type B. Blood pressure 144/94 mm/Hg in left arm C. Positive rubella serum antibody titer D. Copious leukorrhea

Correct Answer is B

Explanation

A. O negative blood type. This is significant for Rh incompatibility if the fetus is Rh-positive, but it is managed through routine prenatal care and does not require immediate intervention at 36 weeks.
B. Blood pressure 144/94 mmHg in left arm. This finding is concerning because it may indicate the development of preeclampsia, which requires immediate medical attention due to the potential risks to both the mother and fetus.
C. Positive rubella serum antibody titer. A positive titer indicates immunity to rubella, which is a good finding in pregnancy and not a concern.
D. Copious leukorrhea. This is common in late pregnancy and typically not a cause for concern unless it is accompanied by signs of infection or rupture of membranes.

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What is the priority nursing intervention to perform on an infant immediately following repair of a myelomeningocele?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["6"]

Explanation

The nurse identifies the following assessment findings in a client who is 36 weeks' gestation. Which should be immediately reported to the provider?

Correct Answer is B

Explanation

What is the priority nursing intervention to perform on an infant immediately following repair of a myelomeningocele?

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