An infant is admitted to the unit with a diagnosis of bladder exstrophy. What should the nurse prioritize when caring for a client with this condition?
Increasing fluid intake
Inserting an indwelling catheter
Maintaining prone positioning
Preventing skin breakdown
The Correct Answer is D
Rationale:
A. Increasing fluid intake is important for overall health but is not the primary concern in the initial management of bladder exstrophy.
B. Inserting a catheter may be necessary but is not the first priority in managing bladder exstrophy.
C. Prone positioning is generally not recommended for infants with bladder exstrophy; supine positioning may be preferable to prevent pressure on the exposed bladder.
D. Preventing skin breakdown is critical due to the constant exposure of the bladder and surrounding skin to urine, leading to a high risk of irritation and infection.
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Correct Answer is D
Explanation
Rationale:
A. Prone positioning is not recommended post-operatively for abdominal surgery and could exacerbate respiratory issues.
B. While monitoring white blood cell count is important, encouraging lung expansion and preventing complications such as atelectasis is a more immediate priority.
C. The client's pain rating is low and does not necessitate immediate administration of acetaminophen.
D. Encouraging the use of an incentive spirometer helps improve lung expansion, which is crucial to prevent atelectasis and promote proper oxygenation, particularly when breath sounds are diminished.
Correct Answer is B
Explanation
Rationale:
A. Enriched bread may contain some calcium, but it's not as rich a source as other options.
B. White beans are a good source of calcium, which is important for bone health in preschoolers.
C. Fortified cereal may contain added calcium, but it may not be as naturally rich as other food sources.
D. While spinach contains calcium, it also contains oxalates, which can inhibit calcium absorption, making it a less effective source of dietary calcium.