A nurse is orienting a newly licensed nurse in caring for an infant with myelomeningocele. Which of the following actions by the new nurse indicates the teaching has been effective?

Choice A reason: Taking an axillary temperature is standard but not specific to myelomeningocele care. While monitoring for infection is important, it does not address the unique need to protect the exposed spinal sac, which is critical to prevent infection and trauma in this condition. Choice B reason: Performing range of motion on the hips risks damaging the myelomeningocele sac, which contains nerve roots. Movement could cause sac rupture or neurological worsening, as the exposed neural tissue is highly vulnerable, making this action contraindicated in this fragile condition. Choice C reason: Side-lying positioning may be used but is not the most critical action. It helps avoid pressure on the sac, but maintaining a dry, sterile dressing is paramount to prevent infection, a life-threatening complication in myelomeningocele due to exposed neural tissue. Choice D reason: Maintaining a dry dressing over the myelomeningocele sac prevents infection and trauma to exposed neural tissue. A sterile, moist environment protects the sac until surgical repair, reducing the risk of meningitis or further neurological damage, indicating effective understanding of this condition’s care.