A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4hrs to prevent urinary retention. The home health nurse notes that the child has developed episodes of sneezing, urticarial, watery eyes, and a rash in the diaper area. What action is most important for the nurse to take?

Correct Answer: B

Rationale: The correct answer is B) Change to latex-free gloves when handling the infant. This is the most important action for the nurse to take because the child is showing signs of an allergic reaction, likely due to a latex allergy. Given that the child has myelomeningocele, which is a neural tube defect, they may have a higher risk of developing allergies. Using latex-free gloves will help prevent further exposure to latex and reduce the risk of exacerbating the allergic symptoms. Option A) Auscultate the lungs for respiratory pneumonia is incorrect because the symptoms described are indicative of an allergic reaction, not respiratory pneumonia. Option C) Draw blood to analyze for streptococcal infection is incorrect because the symptoms are not suggestive of a streptococcal infection but rather an allergic reaction. Option D) Apply zinc oxide to the perineum with each diaper change is incorrect because it addresses diaper rash, which is not the primary concern in this scenario. In an educational context, it is important for healthcare providers to be aware of common allergies, such as latex, especially when caring for vulnerable populations like infants with myelomeningocele. Understanding the signs and symptoms of allergic reactions and knowing how to manage them is crucial in providing safe and effective care.

Correct Answer: B

Rationale: In this scenario, the correct nursing intervention is to "remove restraints one at a time to provide range of motion exercises" (Option B). This is the appropriate action because it promotes the child's comfort and prevents joint stiffness. By removing one restraint at a time, the nurse can assess the child's response, provide necessary care, and ensure proper circulation and skin integrity. Option A is incorrect because waiting for the healthcare provider's advice may delay necessary care and hinder the child's recovery. Option C is incorrect as it does not address the need for range of motion exercises or the potential risks associated with prolonged use of restraints. Option D is also incorrect as it does not prioritize providing range of motion exercises and may lead to skin breakdown if the restraints are left off for too long. Educationally, understanding the rationale behind the correct intervention is crucial for nurses caring for pediatric patients post-cleft lip repair. It is essential to prioritize the child's comfort, mobility, and overall well-being while considering the implications of restraint use. Nurses should be knowledgeable about appropriate interventions to promote optimal outcomes for their pediatric patients.

Correct Answer: B

Rationale: In the case of slipped femoral capital epiphysis, surgical intervention is often required. Post-surgery care is crucial to prevent complications such as infection and ensure proper healing. This care includes monitoring and managing pin and incision sites for signs of infection, promoting wound healing, and preventing postoperative complications. The focus on pin and incision care is essential for the child's recovery and overall well-being.

Correct Answer: A

Rationale: In infants, a weak cry without tears is a classic sign of dehydration. Tears are produced by the lacrimal glands, and reduced tear production is a result of dehydration. This assessment finding should alert the nurse to the infant's dehydration status, requiring prompt intervention to prevent further complications.

Correct Answer: A

Rationale: A cephalohematoma is a collection of blood between the skull and the periosteum. As the blood breaks down, there is an increased risk of jaundice due to the release of bilirubin from the breakdown of red blood cells. Jaundice is a common complication associated with cephalohematoma in neonates. Therefore, the nurse should closely monitor the neonate for signs of jaundice and manage it accordingly.