Which nursing intervention is most appropriate when caring for an infant with a myelomeningocele in the preoperative stage?
1. Placing infant supine to decrease pressure on the sac
2. Appling a heat lamp to facilitate drying and toughening of the sac
3. Measuring head circumference every shift to identify developing hydrocephalus
4. Appling a diaper to prevent contamination of the sac
Correct Answer: 3
Rationale: The infant should be monitored for developing hydrocephalus, so the head circumference should be monitored daily. The infant will be placed prone, not supine, and the defect will be protected from trauma or infection. Therefore, applying heat and a diaper around the defect would not be recommended. A sterile saline dressing may be used to cover the sac to maintain integrity.
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