Nokea
A newborn who has a myelomeningocele and is admitted to the newborn intensive care unit (NICU) to await surgery
A nurse is caring for a newborn who has a myelomeningocele and is admitted to the newborn intensive care unit (NICU) to await surgery. Which of the following nursing goals is priority in the care of this infant?
- A. Promote maternal-infant bonding
- B. Provide age-appropriate stimulation.
- C. Educate the parents about the defect.
- D. Maintain integrity of the sac.
Correct Answer: D
Rationale: The correct answer is D: Maintain integrity of the sac. This is the priority goal because the newborn with myelomeningocele is at risk for infection and further damage if the sac is not properly cared for. By ensuring the sac is clean, covered, and protected, the nurse can help prevent complications such as meningitis. Promoting maternal-infant bonding (A) is important but not the priority at this time. Providing age-appropriate stimulation (B) is not as urgent as ensuring the sac's integrity. Educating the parents about the defect (C) is crucial for long-term care but not the immediate priority.
You may also like to solve these questions
A 2-month-old infant whose provider applied a Pavlik harness 1 week earlier for the treatment of developmental hip dysplasia
A nurse is reinforcing teaching with the mother of a 2-month-old infant whose provider applied a Pavlik harness 1 week earlier for the treatment of developmental hip dysplasia. Which of the following statements by the mother indicates an understanding of the teaching?
- A. I will use powders & lotion on his skin around the harness clasps.
- B. I will remove the harness daily, prior to giving the bath.
- C. I will adjust the harness straps every day.
- D. I will check my baby's skin under the straps frequently.
Correct Answer: D
Rationale: The correct answer is D: I will check my baby's skin under the straps frequently. This is because regularly checking the baby's skin under the harness straps is essential to ensure there are no signs of skin irritation or pressure sores. Failing to do so can lead to skin breakdown and complications.
Choice A is incorrect as using powders and lotions near the clasps can cause friction and increase the risk of skin irritation. Choice B is incorrect as removing the harness daily can disrupt the treatment process and should only be done as instructed by the healthcare provider. Choice C is incorrect as adjusting the harness straps without proper training can affect the effectiveness of the harness and potentially harm the baby.
An infant who has Tetralogy of Fallot and is easily fatigued when eating
A nurse is caring for an infant who has Tetralogy of Fallot and notes that the infant is easily fatigued when eating. Which defect is not present in this cardiac congenital malformation?
- A. Overriding aorta
- B. Pulmonary stenosis
- C. Left ventricular hypertrophy
- D. Ventricular septal defect
Correct Answer: C
Rationale: The correct answer is C: Left ventricular hypertrophy is not present in Tetralogy of Fallot. In Tetralogy of Fallot, the four main defects are pulmonary stenosis, overriding aorta, ventricular septal defect, and right ventricular hypertrophy. Left ventricular hypertrophy is not part of the condition. The infant's fatigue during feeding is likely due to decreased oxygen levels in the blood caused by the pulmonary stenosis and right-to-left shunting at the ventricular septal defect. Choices A, B, and D are all components of Tetralogy of Fallot, making them incorrect options.
A dehydrated child who weighs 10 kg
A dehydrated child has intravenous aid therapy ordered. The child weighs 10 kg. Physician ordered Lactated Ringer's solution 40 ml/kg over 4 hours How many miles per hour will this child receive?
- A. 300ml/hour
- B. 100 mL/hour
- C. 50mL/hour
- D. 200 ml/hour
Correct Answer: B
Rationale: The correct answer is B: 100 mL/hour. To calculate the IV rate, we first multiply the weight of the child (10 kg) by the ordered rate (40 ml/kg) which gives us 400 ml over 4 hours. To convert this to ml per hour, we divide 400 ml by 4 hours, resulting in 100 ml/hour. This calculation ensures the child receives the correct amount of fluid over the specified time frame. Other choices are incorrect because they do not follow the correct calculation method or do not align with the physician's order.
A child who has iron deficiency anemia
A nurse in a pediatric clinic in caring for a child who has iron deficiency anemia and is to start taking ferrous sulfate syrup. Which of the following Instructions should the nurse give the parent?
- A. Administer the medication at meal time
- B. Administer the medication at bedtime.
- C. Offer the medication through a straw
- D. Dilute the medication with 240 mi. (Bar) of milk
Correct Answer: C
Rationale: The correct answer is C: Offer the medication through a straw. This is because iron supplements can stain teeth, and using a straw can help minimize direct contact with the teeth, reducing the risk of staining. Administering the medication at mealtime (choice A) may cause gastrointestinal upset, and administering it at bedtime (choice B) may increase the risk of staining teeth during sleep. Diluting the medication with milk (choice D) is not recommended as calcium in milk can interfere with iron absorption. Offering the medication through a straw is the best option to ensure effective administration while minimizing side effects.
A child who is postoperative following a tonsillectomy
A nurse is collecting data from a child who is postoperative following a tonsillectomy. Which of the following is a clinical manifestation of a hemorrhage?
- A. Drooling
- B. Continuous swallowing
- C. Poor fluid intake
- D. Increased pain
Correct Answer: B
Rationale: The correct answer is B: Continuous swallowing. This is a clinical manifestation of hemorrhage post-tonsillectomy as the child may be swallowing blood. Drooling (A) is more indicative of airway obstruction. Poor fluid intake (C) is a sign of dehydration. Increased pain (D) can be expected postoperatively but is not specific to hemorrhage.