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. Deep, rapid respirations, known as Kussmaul respirations, are typically associated with hyperglycemia and ketoacidosis, not hypoglycemia.
B. Tachycardia is a common symptom of hypoglycemia, as the body releases adrenaline in response to low blood glucose levels, leading to an increased heart rate.
C. Polyuria is associated with hyperglycemia, not hypoglycemia.
D. Dry, flushed skin is typically a sign of dehydration or hyperglycemia, not hypoglycemia.
Correct Answer is D
Explanation
Rationale:
A. Seizures are not a typical complication of polycythemia, though they may occur if the condition progresses to severe levels of blood viscosity.
B. Yellowing of the skin (jaundice) is not associated with polycythemia but with liver conditions.
C. While activity is important, preventing dehydration is more critical in managing polycythemia because dehydration increases blood viscosity, exacerbating the condition.
D. Preventing dehydration is essential as it helps maintain adequate blood flow and reduces the risk of thrombotic events in a child with polycythemia.