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CCRN Critical Care Nursing

Category - Neonatal

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A nurse is performing an admission assessment on a newborn infant with a diagnosis of spina bifida (meningomyelocele). The nurse assesses for a major symptom associated with this type of spina bifida when the nurse:

Checks the capillary refill of the nailbeds of the upper extremities
Tests the urine for blood
Palpates the abdomen for masses
Checks for responses to painful stimuli from the torso downward

Explanation

Answer: D - Newborn infants with spina bifida (meningomyelocele) demonstrate lack of innervation from below the site of the sac that contains the meninges and spinal cord and excess cerebrospinal fluid. They therefore show diminished or no responses to painful in these areas below the sac.

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CCRN Critical Care Nursing

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CCRN Critical Care Nursing

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