Nokea
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.
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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 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.
What occurrence results from obstruction within the ventricles of the brain or inadequate reabsorption of cerebrospinal fluid?
- A. Meningitis
- B. Meningocele
- C. Spina bifida occulta
- D. Hydrocephalus
Correct Answer: D
Rationale: Hydrocephalus is characterized by an increase in cerebrospinal fluid in the ventricles of the brain due to obstruction or inadequate reabsorption.
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 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.