When administering zidovudine to a patient with human immunodeficiency virus (HIV), which action should be the first priority for the nurse?

Choice A rationale:

While educating caregivers on sensory impairment is important for an infant with myelomeningocele, preventing infection takes precedence as the priority nursing intervention.

Choice B rationale:

The correct answer. Preventing infection at the site of the myelomeningocele is crucial to avoid potentially life-threatening complications, such as meningitis. The exposed neural tissue poses a significant infection risk.

Choice C rationale:

Correcting joint contractures is important but is a secondary concern compared to preventing infection, which can have more immediate and severe consequences.

Choice D rationale:

Measuring daily head circumference is important to monitor for hydrocephalus in these infants, but preventing infection remains the higher priority.

Choice A rationale:

Assessing the infant's ability to roll over is unrelated to the situation. The nurse's focus should be on safely retrieving the nasogastric tube without leaving the infant alone.

Choice B rationale:

Using a nesting pillow is not appropriate in this scenario. The nurse should prioritize getting the nasogastric tube rather than introducing unnecessary items into the crib.

Choice C rationale:

Putting the side rail all the way up might hinder the nurse's ability to access the counter and the nasogastric tube. It is not the most effective action in this situation.

Choice D rationale:

Calling for assistance ensures that the infant's safety is maintained while the nurse retrieves the nasogastric tube. Leaving the infant unattended increases the risk of harm, so involving someone else is the appropriate action.