A newborn has a large myelomeningocele. What nursing intervention is priority?

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11ecbb05_caed_df7f_b433_7d541a12b7cd_MD0009_00 Myelomeningocele occurs when the neural tube fails to fuse properly during fetal development. An outpouching of spinal fluid, spinal cord, and nerves covered by only a thin membrane occurs, typically in the lumbar area. The newborn is at high risk for infection at this area. A priority nursing intervention is to cover the area with a sterile, moist dressing to decrease the risk of infection until surgical repair can occur. (Option A) Assessing for an anal wink will assist in the assessment of the level of neurologic deficit but is not a priority intervention. (Option C) Myelomeningocele may decrease the absorption of cerebrospinal fluid, which would place the newborn at risk for hydrocephalus from the excess cerebrospinal fluid. An occipital frontal circumference is needed as a baseline measurement but is not a priority. (Option D) The newborn would be placed in the prone position (with face turned to the side) to prevent rupture of the myelomeningocele. Educational objective: The newborn with a myelomeningocele is at risk for infection. Covering the myelomeningocele with a sterile, moist dressing is indicated to decrease the risk of infection at the site. The infant should be placed on the abdomen (prone) with the face turned to the side.

A Newborn Has a Large Myelomeningocele