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.
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.
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