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 B
Explanation
Rationale:
A. Nausea and vomiting are more commonly associated with hyperglycemia, not hypoglycemia.
B. Shakiness is a common symptom of hypoglycemia, indicating that the parents understand the signs of low blood glucose levels.
C. The onset of hypoglycemia is typically rapid, not slow, which is why quick intervention is necessary.
D. Sweating is a common symptom of hypoglycemia, not hyperglycemia.
Correct Answer is C
Explanation
Rationale:
A. While play therapy can be beneficial, it is not the primary focus for a 10-year-old child’s psychosocial needs related to Erikson’s stage.
B. Encouraging visits from friends supports the child's need for social interaction, which is important for psychosocial development during hospitalization.
C. Encouraging the child to complete school work helps maintain a sense of normalcy and supports the child’s need for achievement and competence, which is central to Erikson’s stage of industry vs. inferiority.
D. Consistency is important, and varying the child's schedule may add stress rather than support their psychosocial needs.