Nokea
What manifestations of increasing ICP in the hydrocephalic child should the nurse be aware of?
- A. High-pitched cry
- B. Unequal pupils
- C. Bulging fontanelles
- D. Diarrhea
- E. Hiccups
Correct Answer: A,B,C
Rationale: Increased intracranial pressure is indicated by a high-pitched cry, unequal pupils, and bulging fontanelles in a hydrocephalic child.
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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.
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.
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.
What body system has the highest risk of congenital anomaly in a child with Down syndrome?
- A. Reproductive system
- B. Genitourinary system
- C. Cardiovascular system
- D. Gastrointestinal system
Correct Answer: C
Rationale: Children with Down syndrome are prone to congenital cardiovascular system deformities.
What characteristics are typical in a child diagnosed with Down syndrome?
- A. Close-set eyes
- B. Simian creases
- C. Wide-spaced front teeth
- D. Protruding tongue
- E. Curved, small fingers
Correct Answer: A,B,D,E
Rationale: Children with Down syndrome have close-set upturned eyes, simian creases, protruding tongue, and curved, small fingers.