Nokea
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.
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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 nursing action will the nurse implement after feeding an infant with hydrocephalus?
- A. Position the infant sitting upright in an infant seat.
- B. Place the infant over the shoulder to burp.
- C. Leave the infant in a side-lying position.
- D. Stimulate the infant by rubbing its feet.
Correct Answer: C
Rationale: Children with hydrocephalus are prone to vomiting; a side-lying position in a quiet atmosphere after feeding reduces the incidence of vomiting.
Parents of a newborn with a unilateral cleft lip are concerned about having the defect repaired. The nurse explains that a child with a cleft lip usually undergoes surgical repair at which time?
- A. Immediately after birth
- B. By 3 months of age
- C. After 12 months of age
- D. Varies in every case
Correct Answer: B
Rationale: A cleft lip is repaired by 3 months of age when weight gain is established and the infant is free of infection.
What should the nurse assess for with this neonate?
- A. Hypoglycemia
- B. Erythroblastosis fetalis
- C. Intracranial hemorrhage
- D. Pancreatic failure
Correct Answer: A
Rationale: The newborn of a mother with diabetes is prone to hypoglycemia due to hyperinsulinism after the abrupt loss of maternal glucose.
When bathing an infant, what sign does the nurse recognize as a sign of developmental hip dysplasia?
- A. Hypotonicity of the leg muscles
- B. One leg is shorter than the other
- C. Broadening and flattening of the buttocks
- D. Two skinfolds on the back of each thigh
Correct Answer: B
Rationale: A shorter leg on the affected side is a sign of developmental hip dysplasia due to the femur slipping out of the acetabulum.