Question

The nurse is admitting a newly delivered neonate with meningocele into the nursery. Which of the following assessments is priority for the nurse to perform?

1) Assessment of the red reflexes
2) Hard palate assessment
3) Trunk incurvation reflex
4) Head and chest circumferences

Answer 1

The priority assessment for a neonate with meningocele is the measurement of head and chest circumferences, which are crucial for identifying complications like hydrocephalus.

Step-by-step explanation:

The priority assessment for a nurse admitting a neonate with meningocele into the nursery should focus on neurological functions, as meningocele is a type of neural tube defect affecting the spine. The most critical initial assessment would be the measurement of head and chest circumferences, as these may provide immediate information about potential increases in intracranial pressure or other neurological concerns that are common with meningocele. Monitoring the size and growth of the head circumference is especially pertinent since it may indicate hydrocephalus, a common complication. Other assessments mentioned, like red reflexes and hard palate assessment, are important in a general neonatal assessment but not as immediately critical as the head and chest circumferences in this particular scenario.