Nokea
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.
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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 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 formula and/or diet should the nurse suggest?
- A. Lifelong high-protein diet
- B. A formula that is low in the amino acid leucine
- C. A soy-based formula
- D. Substitute Lofenalac for some protein foods
Correct Answer: D
Rationale: Lofenalac, a synthetic food low in phenylalanine, is substituted for natural protein foods to support growth in infants with phenylketonuria.
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.