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

A.

Assess motor function in lower extremities

B.

Maintain skin integrity

C.

Monitor intake and output

D.

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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Related Questions

Correct Answer is A

Explanation

A. This position prevents stomach juice from going into the lungs. Elevating the head helps prevent reflux of stomach contents into the trachea and lungs, which can lead to aspiration pneumonia.
B. This position allows food to be easily digested by the stomach. The position primarily focuses on respiratory protection, not digestion.
C. This position helps my baby breathe better by opening the lungs. While elevation can aid breathing, it's primarily to prevent aspiration rather than improving respiratory function.
D. This position keeps pressure off the stomach. It's not primarily about relieving pressure but rather preventing aspiration.

Correct Answer is D

Explanation

A. Keep eye shields on at all times, including when feeding. Incorrect because while eye protection is crucial under the lights, they can be removed during feedings to allow for parent-infant bonding and eye contact.
B. Routinely monitor temperature while the infant is in the crib. Incorrect, because temperature should be closely monitored while the infant is under phototherapy due to potential changes in body temperature caused by the exposure.
C. Tightly swaddle the infant in a blanket. Incorrect, as this would reduce the amount of skin exposed to the phototherapy lights and decrease the treatment's effectiveness.
D. Expose as much of the infant's skin to the lights as possible. Phototherapy is most effective when as much skin as possible is exposed to the lights because it allows for maximum light absorption and more effective bilirubin breakdown.

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