Which interventions should the nurse implement for a newborn with ...

[captainjonesify]

Which interventions should the nurse implement for a newborn with a subgaleal hemorrhage? (Select all that apply.)
 
  a. Monitor bilirubin levels.
  b. Monitor hematocrit levels.
  c. Prepare the newborn for skull radiography.
  d. Monitor the newborn's level of consciousness.
  e. Place a warm compress on the affected area.

Question 2

The most important nursing intervention when caring for an infant with myelomeningocele in the preoperative stage is which?
 
  a. Take vital signs every hour.
  b. Place the infant on the side to decrease pressure on the spinal sac.
  c. Watch for signs that might indicate developing hydrocephalus.
  d. Apply a heat lamp to facilitate drying and toughening of the sac.

[amandanbreshears]

Answer to Question 1

ANS: A, B, D
An increase in serum bilirubin levels may occur as a result of the degrading red blood cells within the hematoma. Monitoring the newborn for changes in level of consciousness and a decrease in the hematocrit are keys to early recognition and management. Computed tomography or magnetic resonance imaging, not skull radiography, is useful in confirming the diagnosis. A warm compress would be contraindicated because it may dilate blood vessels and increase bleeding.

Answer to Question 2

ANS: B
The spinal sac is protected from damage until surgery is performed. Early surgical closure is recommended to prevent local trauma and infection. Monitoring vital signs and watching for signs that might indicate developing hydrocephalus are important interventions, but preventing trauma to the sac is a priority. The sac is kept moist until surgical intervention is done.