what information would the nurse include in the preoperative plan of care for an infant with myelomeningocele
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Nursing Elites

HESI LPN

Pediatric HESI 2024

1. What information should be included in the preoperative plan of care for an infant with myelomeningocele?

Correct answer: B

Rationale: Covering the sac with saline-soaked nonadhesive gauze is essential in the preoperative care of an infant with myelomeningocele. This practice helps prevent infection and maintains moisture around the sac before surgery, promoting optimal healing outcomes. Positioning the infant supine with a pillow under the buttocks may be uncomfortable and unnecessary. Wrapping the infant snugly in a blanket does not address the specific care needs of the myelomeningocele. Applying a diaper over the sac can increase the risk of infection and should be avoided in this case.

2. Which of the following techniques represents the most appropriate method of opening the airway of an infant with no suspected neck injury?

Correct answer: B

Rationale: The correct technique for opening the airway of an infant with no suspected neck injury is to tilt the head back without hyperextending the neck. This method helps to keep the airway open without risking injury to the infant's delicate neck structures. Choice A, lifting up the chin and hyperextending the neck, can potentially harm the infant's neck. Choice C, gently lifting the chin while maintaining slight flexion of the neck, is not as effective as tilting the head back. Choice D is incorrect as infants require a different approach compared to older children or adults due to their anatomical differences.

3. What is the first action a healthcare provider should take before administering a tube feeding to an infant?

Correct answer: B

Rationale: The correct answer is to offer a pacifier to the infant before administering tube feeding. Offering a pacifier helps stimulate the sucking reflex, preparing the infant for feeding and promoting digestion and comfort. Irrigating the tube with water (Choice A) is not typically the first action before tube feeding and may not be necessary. Slowly instilling formula (Choice C) should only be done after the infant is prepared for feeding. Placing the infant in the Trendelenburg position (Choice D) is not necessary and may not be recommended for tube feeding.

4. A 4-year-old child is brought to the emergency department with a suspected fracture. What is the priority nursing action?

Correct answer: A

Rationale: The priority nursing action when a child with a suspected fracture is brought to the emergency department is to immobilize the affected limb. Immobilization helps prevent further injury until a fracture is confirmed or ruled out. Applying ice or elevating the limb can wait until after immobilization has been achieved. Checking the child's neurovascular status is important but is not the priority action in this situation.

5. A parent and 3-month-old infant are visiting the well-baby clinic for a routine examination. What should the nurse include in the accident prevention teaching plan?

Correct answer: D

Rationale: The correct answer is to test the temperature of water before bathing. This is crucial in preventing burns, which is a significant risk for infants due to their sensitive skin. Infants have delicate skin that can be easily burned by water that is too hot. Removing small objects from the floor (Choice A) is important to prevent choking hazards but not directly related to burns. Covering electric outlets with safety plugs (Choice B) is essential to prevent electrocution but does not address the risk of burns specifically. Removing toxic substances from low areas (Choice C) is necessary to prevent poisoning but is not directly related to burns. Therefore, the priority in this scenario is to prevent burns by ensuring the water temperature is safe for the infant.

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