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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is D
Explanation
Rationale:
A. A storybook may provide comfort and information but is less interactive in helping the child process the experience of injections.
B. Playing in the playroom is beneficial for normalizing hospital stays but does not directly address the child’s distress regarding injections.
C. A video game can be a good distraction but does not provide therapeutic engagement with the fear or anxiety related to injections.
D. Allowing the child to play with a needleless syringe and a doll is therapeutic as it gives the child a sense of control and understanding of the injection process, helping to reduce fear and anxiety.
Correct Answer is ["A","C","E"]
Explanation
Rationale:
A. The DTaP vaccine is recommended at 15-18 months, so it would be appropriate to administer it to a 1-year-old child.
B. The rotavirus vaccine is typically given earlier, before the child reaches 1 year of age.
C. The varicella (chickenpox) vaccine is given between 12-15 months of age, so it is appropriate for a 1-year-old.
D. The HPV vaccine is usually administered starting at age 11-12 years, not at 1 year.
E. The MMR (measles, mumps, rubella) vaccine is recommended between 12-15 months of age, making it appropriate for a 1-year-old.