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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is A
Explanation
Rationale:
A. The knee-chest position increases systemic vascular resistance, which helps to divert more blood to the pulmonary circulation, improving oxygenation in a child experiencing a "tet spell" or hypercyanotic episode.
B. The prone position does not help in relieving cyanosis and dyspnea in Tetralogy of Fallot.
C. The supine position with the head turned does not assist in improving oxygenation during a cyanotic episode.
D. The semi-Fowler's position may aid breathing but is less effective than the knee-chest position in managing cyanotic spells.
Correct Answer is D
Explanation
Rationale:
A. Children with sickle cell anemia should receive all recommended immunizations to protect against infections, which can trigger a sickle cell crisis.
B. Participating in sports should be done with caution, and activities that lead to dehydration or overexertion should be avoided.
C. Over-the-counter medications should be used cautiously and under the guidance of a healthcare provider, as some medications may not be suitable for children with sickle cell anemia.
D. Ensuring adequate hydration is crucial for preventing sickle cell crises. Dehydration can increase blood viscosity, leading to sickling of the red blood cells and subsequent pain and complications.