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. Hypertension is not typical for nephrotic syndrome; instead, nephrotic syndrome often presents with low blood pressure or normal blood pressure.
B. Polyuria is more commonly associated with conditions like diabetes mellitus rather than nephrotic syndrome, which typically presents with reduced urine output.
C. Facial edema is a common finding in nephrotic syndrome due to fluid retention and is often noticeable in the periorbital area.
D. Smokey brown urine is indicative of hematuria or glomerulonephritis, not nephrotic syndrome.
Correct Answer is C
Explanation
Rationale:
A. A decreased respiratory rate is not a typical sign of pain in an infant and may indicate other issues.
B. Increased formula consumption is not a specific indicator of pain and could be related to other factors like hunger or comfort.
C. Increased crying episodes are a common sign of pain in infants, as they often use crying to express discomfort or distress.
D. Decreased heart rate is not typically associated with pain and may indicate other conditions.