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. Maintaining a saline-lock is important but not the highest priority in this context.
B. Checking the child's daily weight is a priority to monitor for fluid retention and changes in fluid status, which are critical in managing acute glomerulonephritis.
C. Educating parents is important but comes after ensuring the child's immediate physical needs are addressed.
D. While a no-salt-added diet may be recommended, monitoring fluid status and weight is more urgent for assessing and managing the condition.
Correct Answer is D
Explanation
Rationale:
A. Clear drainage from the ear is more indicative of a ruptured tympanic membrane or an external ear infection (otitis externa) rather than otitis media.
B. Pain when manipulating the earlobe is associated with otitis externa, not otitis media.
C. Erythema and edema of the outer ear may occur with otitis externa but are not common in otitis media, which affects the middle ear.
D. Tugging on the ear is a common sign of discomfort in children with otitis media due to pressure and pain in the middle ear.