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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.
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What nursing action is the most appropriate?
- A. Feed solid foods with the spoon at the side of the mouth.
- B. Puree foods and offer them through a straw.
- C. Place small bites of food in the mouth with a tongue blade.
- D. Offer small, frequent meals of finger foods.
Correct Answer: A
Rationale: Feeding with the side of a spoon at the side of the mouth protects the operative site of a cleft palate repair.
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 nursing action is most important for this nurse to implement?
- A. Align the limbs.
- B. Support the head.
- C. Keep the head lower than the hip.
- D. Check intake and output.
Correct Answer: B
Rationale: The child with hydrocephalus has a heavy head on a small body with poor muscle tone; supporting the head during feeding and moving prevents neck injury.
What is the priority preoperative nursing care of this newborn?
- A. Keep the sac dry.
- B. Diaper snugly.
- C. Position prone in an incubator.
- D. Move from side to side every hour.
Correct Answer: C
Rationale: The infant with meningomyelocele is placed prone in a humidified incubator with the sac covered with sterile saline dressings to protect the lesion.
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.