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
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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Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Fetal breathing. The biophysical profile assesses fetal breathing movements as one of the components indicating fetal well-being.
B. Fetal neck translucency. This is not part of the biophysical profile; it is typically assessed during first-trimester screening for chromosomal abnormalities.
C. Fetal motion. Fetal movements are another component of the biophysical profile, reflecting the fetal central nervous system integrity and oxygenation.
D. Amniotic fluid volume. The assessment of amniotic fluid volume is crucial in determining fetal well-being and adequate fetal renal function.
E. Fetal gender. Gender is not assessed as part of the biophysical profile; the test focuses on fetal physiological parameters related to well-being.
Correct Answer is ["A","B","E","F"]
Explanation
A. Substance use. Parents or caregivers who use substances are more likely to abuse children due to impaired judgment and increased stress levels.
B. Extreme stress. High levels of stress in the family can increase the risk of child abuse as it can lead to frustration and inappropriate coping mechanisms.
C. High socioeconomic background. This is not typically associated with increased risk of child abuse; abuse can occur across all socioeconomic levels, but certain stressors are more prevalent in lower socioeconomic contexts.
D. Strong support system. A strong support system typically acts as a protective factor against child abuse by providing resources and emotional support to caregivers.
E. Prematurity. Premature infants often have increased care needs, which can lead to parental stress and potential abuse.
F. Chronic illness. Children with chronic illnesses may require more care, leading to caregiver stress and higher risk of abuse.
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