Which is the priority nursing intervention for an infant diagnosed with myelomeningocele?
Educating caregivers on sensory impairment.
Preventing infection.
Correction of joint contractures.
Measuring daily head circumference.
The Correct Answer is B
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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
"Does the child have a sore throat currently?”. This choice is important but not the most critical question. The surgery involves tonsillectomy and adenoidectomy, so the child's current sore throat might not be as pertinent as other factors.
Choice B rationale:
"Do the caregivers have soft foods at home for the child?”. This choice is important for post-operative care, but the most crucial consideration is the child's fasting status before surgery.
Choice C rationale:
"When was the last time the child ate or drank anything?”. This choice is correct. It is essential to determine the child's fasting status before surgery to prevent potential complications related to anesthesia and surgery.
Choice D rationale:
"Does the child have any questions about the procedure?”. While ensuring the child's understanding is important, it is not the most critical question regarding preparation for the surgery.
Correct Answer is B
Explanation
Choice A rationale:
Educating caregivers on sensory impairment is important in the care of a child with myelomeningocele, but the priority is to prevent infection. The exposed spinal cord and tissue are at risk of infection.
Choice B rationale:
Preventing infection is the priority for a child with myelomeningocele. The neural tube defect exposes the spinal cord, making the child susceptible to infections that can lead to serious complications.
Choice C rationale:
Correction of joint contractures is important in the overall care of a child with myelomeningocele, but preventing infection takes precedence. Joint contractures can be managed over time, while infection can quickly escalate.
Choice D rationale:
Measuring daily head circumference is essential for assessing hydrocephalus in a child with myelomeningocele, but preventing infection is more urgent. Infection can cause rapid deterioration, while changes in head circumference might be gradual.
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