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    Ati rn 302 paediatrics proctored exam

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

    Explanation & Rationale

    Rationale: A. Performing range of motion on the hips is not the priority and may increase the risk of injury or stress to the infant with myelomeningocele. B. A side-lying position is not appropriate because it increases the risk of pressure and rupture of the sac. The infant should be placed prone with hips slightly flexed and legs abducted to protect the sac. C. An axillary temperature avoids rectal insertion, which could increase the risk of infection due to the sac’s proximity to the anus. D. The sac should be kept moist and covered with a sterile, non-adherent dressing, not dry. Keeping it dry can cause the sac to crack and rupture, increasing infection risk.

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