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What is the nurse's best response?
- A. The light increases the infant's metabolism.'
- B. The light stimulates liver function.'
- C. The light dilates blood vessels.'
- D. The light breaks down bilirubin.'
Correct Answer: D
Rationale: Phototherapy breaks down excess bilirubin to prevent kernicterus, allowing it to be excreted.
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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.
How should the nurse position this infant?
- A. Prone, with the head of the bed elevated
- B. Supine, with the head flat
- C. Side-lying on the operative side
- D. In a semi-Fowler's position
Correct Answer: D
Rationale: A semi-Fowler's position promotes drainage from the ventricles through the shunt in an infant with bulging fontanelles post-ventriculoperitoneal shunt.
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 should they be instructed to provide special attention to in regard to the generalized hypotonicity of the child?
- A. Preventing hyperthermia
- B. Respiratory care
- C. Prevention of diarrhea
- D. Incontinence care
Correct Answer: B
Rationale: Generalized hypotonicity in Down syndrome causes mucus accumulation, increasing the risk of respiratory problems.
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.