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 A, B, C, D, E
Explanation
Rationale:
A. Trust vs. Mistrust: This stage occurs from birth to approximately 18 months of age. During this period, infants learn to trust their caregivers to meet their needs. If their needs are consistently met, they develop a sense of trust; otherwise, they may develop mistrust.
B. Autonomy vs. Shame and Doubt: From 18 months to 3 years, children begin to assert their independence. If caregivers encourage self-sufficient behavior, children become more autonomous; if they're overly criticized, they may develop feelings of shame and doubt.
C. Initiative vs. Guilt: Between the ages of 3 and 5, children start to initiate activities and assert control over their world through play and social interactions. Successful initiation leads to a sense of purpose, while failure results in feelings of guilt.
D. Industry vs. Inferiority: From 6 years to puberty, children compare themselves to their peers. They develop a sense of pride and accomplishment through their successes, or they may feel inferior if they do not measure up.
E. Identity vs. Role Confusion: During adolescence, teens explore different roles and ideas to form a personal identity. A well-established identity leads to the ability to stay true to oneself, while failure to establish an identity results in role confusion.
Correct Answer is C
Explanation
Rationale:
A. Imitating animal sounds is typically expected by around 12 months, so it is not unusual for a 10-month-old to not yet do this.
B. Building a tower of three or four cubes is usually expected around 15-18 months, so it is not concerning at 10 months.
C. By 9-10 months, infants are generally able to sit steadily without support. Difficulty in doing so might indicate developmental delay and should be reported.
D. Turning pages in a book is a skill typically developed around 12 months, so it is not unusual for a 10-month-old to not yet do this.