Nokea
A 1-month-old girl with low-set ears and severe hypotonia has been diagnosed with trisomy 18. Which nursing diagnosis would the nurse identify as most likely?
- A. Interrupted family process related to the child's diagnosis
- B. Deficient knowledge related to the genetic disorder
- C. Grieving related to the child's poor prognosis
- D. Ineffective coping related to the stress of providing care
Correct Answer: C
Rationale: The most likely nursing diagnosis for a 1-month-old girl with trisomy 18, characterized by low-set ears and severe hypotonia, is 'Grieving related to the child's poor prognosis.' Trisomy 18 is associated with a poor prognosis, and families often experience grief as they come to terms with the challenges and uncertainties associated with the condition. 'Interrupted family process' may not be as relevant since the primary focus is on the child's condition. 'Deficient knowledge related to the genetic disorder' could be important but may not be the most likely initial concern, as emotional support for the family is crucial at this point. 'Ineffective coping related to the stress of providing care' is a broad diagnosis that does not specifically address the emotional response to the child's prognosis, which is the primary concern in this case.
You may also like to solve these questions
A child with a diagnosis of diabetes mellitus is being discharged from the hospital. What is important for the nurse to include in the discharge teaching?
- A. Monitor blood glucose levels daily
- B. Administer insulin based on blood glucose levels
- C. Recognize signs of hypoglycemia
- D. Follow a structured meal plan
Correct Answer: D
Rationale: Following a structured meal plan is essential for managing diabetes mellitus. It helps regulate blood glucose levels and ensures proper nutrition. Monitoring blood glucose levels daily is important, not just once a day, to maintain control. Administering insulin based on blood glucose levels is crucial but should be done as per the healthcare provider's instructions, not only when blood glucose is high. Recognizing signs of hypoglycemia is important, but it is equally vital to prevent hypoglycemia by adhering to a consistent meal plan and insulin regimen.
A child has been diagnosed with gastroesophageal reflux disease (GERD). What position should the nurse recommend the child be placed in after eating?
- A. Supine
- B. Prone
- C. Semi-Fowler's
- D. Trendelenburg
Correct Answer: C
Rationale: After eating, it is beneficial to place a child with GERD in a semi-Fowler's position. This position helps prevent reflux by keeping the child's head elevated above the stomach, reducing the chances of gastric contents flowing back into the esophagus. Placing the child supine (lying flat on their back) can worsen reflux symptoms by allowing gravity to work against the natural flow of gastric contents. Prone position (lying on the stomach) is not recommended due to the increased risk of aspiration. Trendelenburg position (feet elevated above head) is also inappropriate as it can lead to increased pressure on the abdomen, potentially worsening reflux symptoms.
How should you care for an alert 4-year-old child with a mild airway obstruction, who has respiratory distress, a strong cough, and normal skin color?
- A. Back blows, abdominal thrusts, transport
- B. Oxygen, avoiding agitation, transport
- C. Assisting ventilations, back blows, transport
- D. Chest thrusts, finger sweeps, transport
Correct Answer: B
Rationale: The correct approach for an alert 4-year-old child with a mild airway obstruction, respiratory distress, a strong cough, and normal skin color is to provide oxygen, avoid agitation, and arrange for transport. Oxygen helps support breathing, avoiding agitation prevents worsening of the obstruction, and transport ensures the child receives further medical evaluation and treatment. Choices A, C, and D involve techniques that are not recommended for a mild airway obstruction in this scenario. Back blows, abdominal thrusts, chest thrusts, and finger sweeps are interventions used for different situations and not suitable for a child with the described symptoms.
The nurse is admitting a newborn with hypospadias to the nursery. The nurse expects which finding in this newborn?
- A. absence of a urethral opening
- B. penis appears shorter than usual for age
- C. the urethral opening is along the dorsal surface of the penis
- D. the urethral opening is along the ventral surface of the penis
Correct Answer: D
Rationale: Hypospadias is a congenital condition where the urethral opening is located along the ventral surface of the penis, not the dorsal surface (Choice C) or absent (Choice A). This leads to the characteristic appearance of a ventrally displaced urethral meatus. The penis may appear normal in size but with the urethral opening positioned abnormally (Choice D), rather than being shorter than usual (Choice B). Therefore, the correct expectation for a newborn with hypospadias is that the urethral opening is along the ventral surface of the penis, making Choice D the correct answer.
When caring for a neonate with a suspected tracheoesophageal fistula, what nursing care should be included?
- A. Elevating the head but giving nothing by mouth
- B. Elevating the head for feedings
- C. Feeding glucose water only
- D. Avoiding suctioning unless the infant is cyanotic
Correct Answer: A
Rationale: In a neonate with a suspected tracheoesophageal fistula, elevating the head but giving nothing by mouth is crucial to prevent aspiration. Placing the neonate in a semi-upright position helps reduce the risk of reflux and aspiration of gastric contents into the lungs. Elevating the head for feedings (Choice B) would still pose a risk of aspiration as the neonate may aspirate during feeding. Feeding glucose water only (Choice C) is not appropriate and does not address the risk of aspiration associated with a tracheoesophageal fistula. Avoiding suctioning unless the infant is cyanotic (Choice D) is incorrect because suctioning may be necessary for maintaining airway patency, regardless of cyanosis, in a neonate with a suspected tracheoesophageal fistula.