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How should the nurse position this infant?
- A. Prone, with the head of the bed elevated
- B. Supine, with the head flat
- C. Side-lying on the operative side
- D. In a semi-Fowler's position
Correct Answer: D
Rationale: A semi-Fowler's position promotes drainage from the ventricles through the shunt in an infant with bulging fontanelles post-ventriculoperitoneal shunt.
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What assessment madThe nurse is caring for a macrosomic newborn of a woman diagnosed with gestational diabetes immediately after birth.e by the nurse would lead the nurse to suspect hip dysplasia?
- A. Asymmetrical gluteal folds
- B. Limited adduction of the affected side
- C. Foot turned inward
- D. Deep inguinal creases
Correct Answer: A
Rationale: Asymmetrical gluteal folds indicate hip dysplasia due to the femur slipping out of the acetabulum.
What is the most appropriate response?
- A. Cystic fibrosis is a chromosomal defect.'
- B. Cystic fibrosis is a metabolic defect.'
- C. Cystic fibrosis is a malformation present at birth.'
- D. Cystic fibrosis is a blood disorder.'
Correct Answer: B
Rationale: Cystic fibrosis is an inborn error of metabolism due to a deficiency of an enzyme necessary for cell metabolism.
The home health nurse is educating parents on home phototherapy. What will the nurse include when providing information to these parents?
- A. Cover the infant's eyes when under the light.
- B. Use a three-prong plug.
- C. Keep a diaper in place.
- D. Place the light source on an absorbent surface.
- E. Expose as much skin as possible.
Correct Answer: B,C,E
Rationale: Home phototherapy instructions include using a three-prong plug, keeping a diaper in place, and exposing as much skin as possible; the light source should be on a nonabsorbent surface, and eyes do not need covering.
What would be included in the plan of care for a child just returned to the floor from surgery in which a clubfoot was repaired?
- A. Keep cast uncovered to allow drying.
- B. Check toes for capillary refill.
- C. Circle with a pen any area of bleeding on the cast.
- D. Keep casted leg lowered.
- E. Observe for skin irritation.
Correct Answer: A,B,C,E
Rationale: The cast should be kept uncovered, toes checked for capillary refill, bleeding areas marked, and skin observed for irritation; the leg should be elevated.
The nurse knows that what is the usual treatment for an infant with this diagnosis?
- A. A Pavlik harness
- B. A body spica cast
- C. Traction
- D. Triple-diapering
Correct Answer: A
Rationale: For infants over 2 months with developmental hip dysplasia, a Pavlik harness is used for longer-term immobilization.