Nokea
The mother of an infant with myelomeningocele asks if her baby is likely to have any other defects. The nurse responds based on the understanding that myelomeningocele is commonly associated with which disorder?
- A. Excessive cerebrospinal fluid within the cranial cavity.
- B. Generally small head.
- C. Congenital absence of the cranium vault.
- D. Overriding of the cranial sutures.
Correct Answer: A
Rationale: Myelomeningocele is often associated with hydrocephalus, characterized by excessive cerebrospinal fluid in the cranial cavity, due to impaired cerebrospinal fluid circulation.
You may also like to solve these questions
The nurse is preparing to administer the last dose of ceftriaxone (Rocephin) before discharge to a 1-year-old but finds the I.V. has occluded. The nurse should:
- A. Restart the I.V.
- B. Administer the medication intramuscularly.
- C. Arrange for early discharge.
- D. Ask the provider to request an order change.
Correct Answer: B
Rationale: Administering ceftriaxone intramuscularly is appropriate when the I.V. is occluded, ensuring the child receives the final dose before discharge.
An infant is admitted to the pediatric unit with a diagnosis of hypertrophic pyloric stenosis after vomiting for several days. Which of the following nursing diagnoses should be the priority?
- A. Deficient fluid volume related to prolonged vomiting.
- B. Ineffective airway clearance related to impaired swallowing.
- C. Imbalanced nutrition: Less than body requirements.
- D. Bowel incontinence related to abdominal pain.
Correct Answer: A
Rationale: Prolonged vomiting in pyloric stenosis leads to significant fluid loss, making fluid volume deficit the priority.
Which sign should lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation?
- A. Hemorrhagic skin rash.
- B. Edema.
- C. Cyanosis.
- D. Dyspnea on exertion.
Correct Answer: A
Rationale: A hemorrhagic rash, such as petechiae or purpura, is a hallmark of disseminated intravascular coagulation in meningitis, indicating clotting abnormalities.
When assessing for pain in a toddler, which of the following methods should be the most appropriate?
- A. Ask the child about the pain.
- B. Observe the child for restlessness.
- C. Use a numeric pain scale.
- D. Assess for changes in vital signs.
Correct Answer: B
Rationale: Toddlers cannot reliably verbalize pain, so observing behavior like restlessness is most appropriate.
Which complication is the nurse most concerned about in an obese child?
- A. Asthma.
- B. Type 2 diabetes.
- C. Seasonal allergies.
- D. Iron deficiency.
Correct Answer: B
Rationale: Obesity increases the risk of type 2 diabetes due to insulin resistance. Asthma and allergies may occur, but diabetes is a more significant concern. Iron deficiency is unrelated.