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The nurse is obtaining intake information on a new patient being seen for preconception care and notes a family history of neural tube defectsW. hat interventions can the nurse suggest to this woman to help prevent neural tube anomalies in a developing fetus?
- A. Avoid drug use.
- B. Follow a low-calorie, low-protein diet.
- C. Take a folic acid supplement every day.
- D. Exercise daily.
- E. Maintain bed rest during the first trimester.
Correct Answer: A,C
Rationale: Avoiding drug use and taking a daily folic acid supplement (0.4 mg) until the 12th week of pregnancy reduces the risk of neural tube defects.
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What will the nurse include in the plan of care when caring for an infant with an intracranial hemorrhage?
- A. Keep positioned with head elevated.
- B. Feed slowly to reduce possibility of vomiting.
- C. Stimulate often to maintain level of consciousness.
- D. Hold and coddle frequently to stimulate.
- E. Observe for increased intracranial pressure.
Correct Answer: A,B,E
Rationale: Care includes keeping the head elevated, feeding slowly to prevent vomiting, and monitoring for increased intracranial pressure, while avoiding stimulation.
What is the most appropriate nursing action for the infant having phototherapy?
- A. Cover the infant's head with a hat.
- B. Dress the infant lightly in a T-shirt.
- C. Keep the infant's eyes covered.
- D. Reposition the infant at least every 4 to 8 hours.
Correct Answer: C
Rationale: The infant's eyes are protected with patches during phototherapy to prevent damage from high-intensity lights.
What is the most appropriate response?
- A. Elevate the child's head.
- B. Check bowel sounds.
- C. Record retention of feeding.
- D. Notify the charge nurse of possible malabsorption.
Correct Answer: D
Rationale: An increasing abdominal girth in a child with a ventriculoperitoneal shunt may indicate malabsorption of cerebrospinal fluid, requiring immediate notification.
The nurse in the newborn nursery is watchful for neonatal abstinence syndrome in the newborn of a mother who took opioids during pregnancyWhat would be the manifestations of this syndrome?
- A. Body tremors
- B. Excessive sneezing
- C. Hyperirritability
- D. Drowsiness
- E. Excessive appetite
Correct Answer: A,B,C
Rationale: Neonatal abstinence syndrome manifests as tremors, hyperirritability, and excessive sneezing due to opioid withdrawal.
What body system has the highest risk of congenital anomaly in a child with Down syndrome?
- A. Reproductive system
- B. Genitourinary system
- C. Cardiovascular system
- D. Gastrointestinal system
Correct Answer: C
Rationale: Children with Down syndrome are prone to congenital cardiovascular system deformities.