Priority nursing action while caring for an infant with meningocele?

AIIMS Delhi NO - 2017

Child Health Nursing (Pediatrics)

Medium

Appeared in: AIIMS Delhi NO - 2017

Explanation

A meningocele is a neural tube defect where a sac containing meninges and cerebrospinal fluid (CSF) protrudes through the spine.
The sac is covered by a thin, fragile membrane that is highly susceptible to rupture and infection.
A rupture creates a direct portal for pathogens to enter the central nervous system, leading to potentially fatal meningitis.
Therefore, protecting the sac from injury and contamination is the most critical and immediate nursing priority to prevent life-threatening complications.

Option A: While preventing dehydration is important for any infant, it is not the most immediate life-threatening risk associated with a meningocele. A central nervous system infection from a ruptured sac is a more urgent concern.
Option C: Early ambulation is contraindicated. Placing the infant on their back or encouraging movement that could put pressure on the sac would increase the risk of rupture.
Option D: Maintaining a strict intake and output (I/O) chart is a standard nursing practice for monitoring hydration and renal function. It is part of good overall care but is secondary to the immediate priority of preventing sac rupture and infection.

Clinical Relevance

Nursing practice connection: Safe nursing care depends on performing Priority nursing care for an infant with meningocele in the correct sequence, documenting the action clearly, and monitoring for the expected response.
The nurse's primary role in pre-operative care for a meningocele is meticulous protection of the sac to prevent meningitis, a major cause of mortality and morbidity.
Positioning is key: the infant must be kept in a prone or side-lying position to avoid any pressure on the defect.
Nurses must constantly monitor for CSF leakage, signs of infection, and changes in neurological status (like a high-pitched cry or bulging fontanel) that could indicate hydrocephalus or meningitis.

How to Approach the Question

First, identify the question type. This is a 'priority' question, which asks for the most important nursing action.
Identify the core medical condition: 'meningocele'. Recall the pathophysiology: a sac containing meninges and CSF is exposed.
Analyze the primary risks associated with this condition. The greatest and most immediate risk is rupture of the sac, leading to a direct central nervous system infection (meningitis).
Evaluate each option based on this primary risk. Does the action address the most immediate, life-threatening problem?
Option A (dehydration) and D (I/O chart) are general care. Option C (ambulation) is harmful. Option B (preventing infection) directly addresses the main life-threatening risk.
Therefore, preventing infection of the sac is the highest priority.

Concept Tested & Keywords

Concept Tested: Priority nursing care for an infant with meningocele.
Stem keywords: Priority nursing action, infant, meningocele
Lead-in keywords: Priority
Clinical cues: Age/sex group narrows the expected diagnosis, intervention, or normal reference range.

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E6 Text Book Of Pediatric Nursing 3rd Panchali Pal — Part 2 (pp 239-476 of 713) pp. 223-225, 221-223