211 Test 2 - Spina Bifida

The nurse is caring for a newborn infant with spina bifida (myelomeningocele) who is scheduled for surgical closure of the sac. In the preoperative period, which is the priority problem? 1 Choking 2 Infection 3 Inability to tolerate stimulation 4 Delayed growth and development

2 Infection Rationale: A myelomeningocele is a type of spina bifida that results from failure of the neural tube to close during embryonic development. With a myelomeningocele, protrusion of the meninges, cerebrospinal fluid, nerve roots, and a portion of the spinal cord occurs. The newborn with spina bifida is at risk for infection before the closure of the sac, which is done soon after birth. Initial care of the newborn with myelomeningocele involves prevention of infection. A sterile normal saline dressing is placed over the sac to maintain moisture of the sac and its contents and to prevent tearing or breakdown of the skin integrity at the site. Any opening in the sac greatly increases the risk of infection of the central nervous system. Choking and inability to tolerate stimulation are not priority problems with this defect. Delayed growth and development is a problem for the infant with myelomeningocele, but preventing infection has priority in the preoperative period.

The nurse is monitoring an infant for signs of increased intracranial pressure. On assessment of the fontanelles, the nurse notes that the anterior fontanelle bulges when the infant is sleeping. Based on this finding, which is the priority nursing action? 1 Increase oral fluids. 2 Document the finding. 3 Notify the primary health care provider (PHCP). 4 Place the infant supine in a side-lying position.

3 Notify the primary health care provider (PHCP). Rationale: The anterior fontanelle is diamond shaped and is located on the top of the head. It would be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. A larger-than-normal fontanelle may be a sign of increased intracranial pressure (ICP) within the skull. Although the anterior fontanelle may bulge slightly when the infant cries, bulging at rest may indicate ICP. Increasing oral fluids and placing the infant in a side-lying position are inaccurate interventions and will not be helpful. Although the nurse would document the finding, the priority action would be to report the finding to the PHCP.

The nurse is caring for a newborn with spina bifida (myelomeningocele type) who is scheduled for the removal of the gibbus (sac on the back filled with cerebrospinal fluid, meninges, and some of the spinal cord). Which is the priority nursing action in the preoperative period? 1 Check the blood pressure. 2 Check specific gravity of the urine. 3 Check the anterior fontanel for depression. 4 Maintain moisture of the normal saline dressing on the gibbus area.

4 Maintain moisture of the normal saline dressing on the gibbus area. Rationale: The newborn is at risk for infection before closure of the gibbus. A sterile normal saline dressing is placed over the gibbus to maintain moisture of the gibbus and its contents. This prevents tearing or breakdown of the skin integrity at the site. Blood pressure is difficult to determine during the newborn period and is not the best indicator of infection. Urine concentration is not well developed in the newborn stage of development. Depression of the anterior fontanel is a sign of dehydration. With spina bifida, an increase in intracranial pressure is more of a priority. A complication of spina bifida would demonstrate a bulging or taut anterior fontanel.

The nurse employed in a neonatal intensive care nursery receives a telephone call from the delivery room and is told that a newborn with spina bifida (myelomeningocele type) will be transported to the nursery. The maternity nurse prepares for the arrival of the newborn and places which priority item at the newborn's bedside? 1 A rectal thermometer 2 A blood pressure cuff 3 A specific gravity urinometer 4 A bottle of sterile normal saline

4 A bottle of sterile normal saline Rationale: Spina bifida is a central nervous system defect that results from failure of the neural tube to close during embryonic development. The newborn with spina bifida is at risk for infection before the closure of the sac, which is done soon after birth. A sterile normal saline dressing is placed over the sac to maintain moisture of the sac and its contents. This prevents tearing or breakdown of the skin integrity at the site. A thermometer will be needed to assess temperature, but in this newborn the priority is to maintain sterile normal saline dressings over the sac. Blood pressure may be difficult to assess during the newborn period and is not the best indicator of infection. Urine concentration is not well developed in the newborn stage of development.

The nurse should anticipate that which medication is the most likely to be prescribed prophylactically for a child with spina bifida (myelomeningocele) who has a neurogenic bladder? 1 Prednisone 2 Sulfasalazine 3 Furosemide 4 Intravenous immune globulin (IVIG)

2 Sulfasalazine Rationale: A neurogenic bladder prevents the bladder from completely emptying because of the decrease in muscle tone. The most likely medication to be prescribed to prevent urinary tract infection would be an antibiotic. A common prescribed medication is sulfasalazine. Prednisone relieves allergic reactions and inflammation rather than preventing infection. Furosemide promotes diuresis and decreases edema caused by heart failure. IVIG assists with antibody production in immunocompromised clients.

The nurse is creating a plan of care for a newborn infant with spina bifida (myelomeningocele type). The nurse includes assessment measures in the plan to monitor for increased intracranial pressure. Which assessment technique would be performed that will best detect the presence of an increase in intracranial pressure? 1 Check urine for specific gravity. 2 Monitor for signs of dehydration. 3 Assess anterior fontanel for bulging. 4 Assess blood pressure for signs of hypotension.

3 Assess anterior fontanel for bulging. Rationale: A bulging or taut anterior fontanel would indicate the presence of increased intracranial pressure. Urine concentrating ability is not well developed at the newborn stage of development. Monitoring for signs of dehydration will not provide data related to increased intracranial pressure. Blood pressure is difficult to assess during the newborn period and is not the best indicator of intracranial pressure.

The nurse is caring for a newborn with a diagnosis of spina bifida (myelomeningocele). Which would the nurse perform to monitor for a major symptom of this condition? 1 Test the urine for blood. 2 Palpate the abdomen for masses. 3 Check for responses to painful stimuli from the torso downward. 4 Check the capillary refill on the nail beds of the upper extremities.

3 Check for responses to painful stimuli from the torso downward. Rationale: Newborns with spina bifida (myelomeningocele type) demonstrate lack of nerve innervation from below the site of the gibbus (sac containing the meninges and spinal cord). They therefore show diminished or no responses to painful stimuli in the areas below the gibbus. Options 1, 2, and 4 are incorrect because the area above the gibbus is not affected. The capillary refill would be normal. The urine would not have blood present. If the kidneys are affected, proteinuria could be present, but this is not generally noted in the newborn period. No abdominal masses are present.

The nurse is assisting in developing a plan of care for a newborn with spina bifida (myelomeningocele type). The nurse includes measures in the plan to monitor for increased intracranial pressure (ICP). Which action will detect the presence of an increase in ICP? 1 Monitoring for signs of dehydration 2 Monitoring urine for specific gravity 3 Monitoring the anterior fontanel for bulging 4 Monitoring blood pressure for signs of hypotension

3 Monitoring the anterior fontanel for bulging Rationale: A bulging or taut anterior fontanel indicates the presence of increased ICP. Monitoring for signs of dehydration will not provide data related to increased ICP. Urine concentration is also not well developed in the newborn stage of development. Blood pressure is difficult to assess during the newborn period and is not the best indicator of increased ICP.

The nurse is caring for an infant with spina bifida (myelomeningocele type) who had the sac on the back containing cerebrospinal fluid, the meninges, and the nerves (gibbus) surgically removed. The nursing plan of care for the postoperative period would include which action to maintain the infant's safety? 1 Covering the back dressing with a binder 2 Placing the infant in a head-down position 3 Strapping the infant in a baby seat sitting up 4 Elevating the head with the infant in the prone position

4 Elevating the head with the infant in the prone position Rationale: Elevating the head will decrease the chance that cerebrospinal fluid will accumulate in the cranial cavity. The infant needs to be prone or side-lying to decrease the pressure on the surgical site on the back. Binders and a baby seat would not be used because of the pressure they would exert on the surgical site.