A nurse is caring for a newborn who has myelomeningocele. Which of the following nursing goals has the priority in the care of this infant?
Promote maternal-infant bonding.
Maintain the integrity of the sac.
Provide age-appropriate stimulation.
Educate the parents about the defect.
The Correct Answer is B
Rationale:
A. Promoting maternal-infant bonding is important but is secondary to addressing immediate physical concerns.
B. Maintaining the integrity of the sac is the priority in managing myelomeningocele. The sac should be protected from rupture or infection to prevent damage to the spinal cord and nerves.
C. Providing age-appropriate stimulation is important for development but is not as urgent as protecting the physical integrity of the sac.
D. Educating the parents about the defect is crucial for long-term care but does not take precedence over immediate physical needs.
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Correct Answer is C
Explanation
Rationale:
A. While heart failure can occur in many congenital heart defects, it is not the most specific condition commonly associated with tetralogy of Fallot.
B. Asthma is not typically associated with tetralogy of Fallot. It is a respiratory condition that does not have a direct link to congenital heart defects.
C. Tetralogy of Fallot is associated with polycythemia due to chronic hypoxemia. The body produces more red blood cells in response to low oxygen levels, leading to an increased hematocrit.
D. While pulmonary hypertension can occur in congenital heart defects, tetralogy of Fallot is more directly associated with polycythemia as a result of the decreased blood flow to the lungs.
Correct Answer is A
Explanation
Rationale:
A. Acetaminophen is appropriate for managing mild discomfort post-procedure.
B. Tub baths are generally avoided for the first few days to prevent infection at the catheterization site; sponge baths are preferred.
C. Keeping the child home for 1 week might be excessive; follow the healthcare provider's specific instructions regarding activity and school return.
D. Clear liquids are typically offered as tolerated, but the primary concern post-procedure is monitoring the insertion site and ensuring the child rests adequately.