Which is the priority nursing intervention when caring for a ...

[OSWALD]

Which is the priority nursing intervention when caring for a neonate who is born with bladder exstrophy?
 
  1. Measuring intake and output
  2. Inserting a Foley catheter
  3. Covering the defect with sterile plastic wrap
  4. Palpating the bladder mass to ensure urine is expelled

Question 2

The nurse is preparing material to instruct a client who has given birth to her first child. What aspect of teaching is most important?
 
  1. Determine if fatherinfant attachment is taking place.
  2. Discuss adaptation to grandparenthood by her parents.
  3. Describe the likely reaction of siblings to the new baby.
  4. Assist the mother in identifying behavior cues of the baby.

[Athena23]

Answer to Question 1

3
Explanation:
1. Because the bladder constantly drains onto the skin of the abdomen, measuring output is not possible.
2. The bladder is open to the abdomen. A Foley catheter cannot be inserted.
3. This reduces the contamination of the bladder, which should be sterile.
4. The bladder is very sensitive and palpation would cause unnecessary pain.

Answer to Question 2

4
Explanation:
1. Although fatherinfant attachment is important, the mother is the main client, and teaching her directly is a higher priority.
2. Adaptation to grandparenthood is a task for her parents and not a high priority for teaching the new mother.
3. This is not appropriate because the baby has no siblings.
4. Helping the mother to identify her baby's behavior cues facilitates the acquaintance phase of maternalinfant attachment.