A nurse is caring for a client receiving mechanical ventilation via an endotracheal (ET) tube. The high-pressure alarm is beeping, and the client is experiencing respiratory distress. The nurse is unable to determine the cause of the alarm. Which of the following actions should the nurse take?
A.
Re-evaluate the client for an ET cuff leak.
B.
Assess for disconnected tubing.
C.
Decrease the ventilator flow rate.
D.
Deliver breaths manually with a resuscitation bag.
The correct answer and Explanation is :
The correct answer is C. Provide a latex-free environment.
Infants with spina bifida, particularly those with myelomeningocele, are at an increased risk of developing latex allergies due to frequent exposure to latex products during surgeries, catheterizations, and other medical procedures. Therefore, providing a latex-free environment is a critical intervention to prevent allergic reactions, which can range from mild to severe (anaphylaxis).
Explanation of Other Options:
- A. Limit visitors to immediate family members: There is no specific reason to restrict visitors for infants with spina bifida, unless the infant has another condition that makes infection control necessary, such as during the postoperative period where infection risk is high. However, limiting visitors is not a standard intervention related to spina bifida or myelomeningocele repair surgery.
- B. Maintain the infant in the supine position: Placing an infant with myelomeningocele in the supine (on their back) position could put pressure on the exposed neural sac, increasing the risk of rupture and infection. Instead, the infant should be placed in a prone (on their stomach) or side-lying position before surgery to protect the sac from damage and reduce the risk of infection or further injury.
- D. Initiate contact precautions: Contact precautions are typically used for patients with infectious conditions that can spread through direct or indirect contact. Spina bifida and myelomeningocele are congenital conditions, and the infant does not inherently require contact precautions unless they develop an infection, such as meningitis or a wound infection after surgery.
In summary, maintaining a latex-free environment is crucial for infants with spina bifida due to their heightened risk of latex allergies.