Question

A nurse is caring for a newborn with spina bifida (myelomeningocele type) who is scheduled for the removal of the gibbus (sac on the back filled with cerebrospinal fluid, meninges, and some of the spinal cord). In the preoperative period, the priority nursing action is to monitor:

a) Blood pressure.

b) Respiratory rate.

c) Temperature.

d) Neurological status.

Answer 1

The priority nursing action in the preoperative period for a newborn with myelomeningocele type spina bifida is to monitor the neurological status, due to the potential for severe neurological symptoms and the vulnerability of the tissue within the sac.

Step-by-step explanation:

In the preoperative period for a newborn with myelomeningocele type spina bifida, the priority nursing action is to monitor the child's neurological status. This is because myelomeningocele involves the protrusion of meninges and spinal nerves through the vertebral column, which can cause severe neurological symptoms. Monitoring neurological status is crucial to detect any changes or complications that could arise before the surgery to remove the gibbus. It's also important to ensure the sac is not compromised, as it contains part of the spinal cord and cerebral spinal fluid (CSF), making it particularly vulnerable to trauma and infection.

Moreover, care must be taken to maintain the integrity of the sac, prevent infection, and ensure the infant remains comfortable and stable. While monitoring of blood pressure, respiratory rate, and temperature are routine preoperative procedures, maintaining the neurological function is a top priority due to the direct association with potential damage to the nervous tissues in cases of myelomeningocele.