Nokea
What is the most appropriate response?
- A. Cystic fibrosis is a chromosomal defect.'
- B. Cystic fibrosis is a metabolic defect.'
- C. Cystic fibrosis is a malformation present at birth.'
- D. Cystic fibrosis is a blood disorder.'
Correct Answer: B
Rationale: Cystic fibrosis is an inborn error of metabolism due to a deficiency of an enzyme necessary for cell metabolism.
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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.
The home health nurse is educating parents on home phototherapy. What will the nurse include when providing information to these parents?
- A. Cover the infant's eyes when under the light.
- B. Use a three-prong plug.
- C. Keep a diaper in place.
- D. Place the light source on an absorbent surface.
- E. Expose as much skin as possible.
Correct Answer: B,C,E
Rationale: Home phototherapy instructions include using a three-prong plug, keeping a diaper in place, and exposing as much skin as possible; the light source should be on a nonabsorbent surface, and eyes do not need covering.
What will the nurse instruct the parents to report immediately?
- A. Facial paralysis
- B. Ear infections
- C. Increased intracranial pressure (ICP)
- D. Drooling
Correct Answer: B
Rationale: Children with cleft palate are at risk for ear infections; parents should report signs of earache immediately to the healthcare provider.
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.
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.