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 D
Explanation
Rationale:
A. Developing autonomy is typically associated with increased independence and exploring new skills, not behaviors seen in a distressed or hospitalized child.
B. While anxiety may be present, the behavior of turning away and thumb-sucking more strongly suggests regression.
C. Resentment toward the mother would not typically result in the described behavior of thumb-sucking and turning away from the nurse.
D. Regression is when a child reverts to earlier behaviors, such as thumb-sucking, as a coping mechanism in response to stress or separation from the primary caregiver.
Correct Answer is A
Explanation
Rationale:
A. The knee-chest position increases systemic vascular resistance, which helps to divert more blood to the pulmonary circulation, improving oxygenation in a child experiencing a "tet spell" or hypercyanotic episode.
B. The prone position does not help in relieving cyanosis and dyspnea in Tetralogy of Fallot.
C. The supine position with the head turned does not assist in improving oxygenation during a cyanotic episode.
D. The semi-Fowler's position may aid breathing but is less effective than the knee-chest position in managing cyanotic spells.