Question

The nurse is caring for a newborn with a diagnosis of spina bifida (myelomeningocele). Which should the nurse perform to monitor for a major symptom of this condition?

a. Assess the fontanelle for bulging
b. Measure head circumference regularly
c. Monitor for signs of respiratory distress
d. Check for the presence of a dimple or tuft of hair over the spine

Answer 1

The nurse should measure head circumference regularly to monitor for a major symptom of spina bifida (myelomeningocele).

Step-by-step explanation:

To monitor for a major symptom of spina bifida (myelomeningocele), the nurse should measure head circumference regularly. Spina bifida is a birth defect of the spinal cord that causes the meninges and neural tissue to emerge through the vertebral column. Measuring head circumference can help identify any abnormal growth or fluid accumulation in the brain, which is a common complication of spina bifida.