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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?

A.

Promote maternal-infant bonding.

B.

Maintain the integrity of the sac.

C.

Provide age-appropriate stimulation.

D.

Educate the parents about the defect.

Answer and Explanation

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. A stool fat content analysis can indicate malabsorption issues but is not definitive for cystic fibrosis.

B. Pulmonary function tests assess lung function but do not confirm cystic fibrosis.

C. The sweat chloride test is the primary diagnostic test for cystic fibrosis, as it measures the amount of chloride in sweat, which is elevated in this condition.

D. A sputum culture can help identify respiratory infections but does not confirm cystic fibrosis.

Correct Answer is A

Explanation

Rationale:

A. Positioning the child laterally (on their side) is important to maintain an open airway and prevent aspiration during a seizure.

B. Restraining the child's arms is not recommended and could cause injury.

C. Using a padded tongue blade is not advised and could cause harm; the focus should be on protecting the child from injury.

D. Attempting to stop the seizure is not effective; instead, focus on ensuring safety and providing appropriate medical care.

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