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. Turning the head to the side is not recommended, as it can cause blood to drain into the throat.
B. Applying pressure to the forehead does not help control nasal bleeding.
C. Sitting upright and applying pressure to the sides of the nose is the correct action to stop the bleeding and prevent blood from going down the throat.
D. Keeping the child flat can increase the risk of blood entering the airway, which can lead to aspiration.
Correct Answer is D
Explanation
Rationale:
A. Seizure precautions are necessary due to the risk of seizures in bacterial meningitis.
B. A private room is necessary to reduce the spread of infection to others.
C. Semi-Fowler's position helps reduce intracranial pressure and is appropriate in managing bacterial meningitis.
D. Measuring head circumference every shift is not typically required for a 6-year-old with bacterial meningitis, as it is more relevant in infants where rapid head growth could indicate increased intracranial pressure.