Nokea
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.
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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.
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.
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.
Parents of a newborn with a unilateral cleft lip are concerned about having the defect repaired. The nurse explains that a child with a cleft lip usually undergoes surgical repair at which time?
- A. Immediately after birth
- B. By 3 months of age
- C. After 12 months of age
- D. Varies in every case
Correct Answer: B
Rationale: A cleft lip is repaired by 3 months of age when weight gain is established and the infant is free of infection.
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.