Nokea
What nursing action will the nurse implement after feeding an infant with hydrocephalus?
- A. Position the infant sitting upright in an infant seat.
- B. Place the infant over the shoulder to burp.
- C. Leave the infant in a side-lying position.
- D. Stimulate the infant by rubbing its feet.
Correct Answer: C
Rationale: Children with hydrocephalus are prone to vomiting; a side-lying position in a quiet atmosphere after feeding reduces the incidence of vomiting.
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What is the most appropriate response?
- A. Elevate the child's head.
- B. Check bowel sounds.
- C. Record retention of feeding.
- D. Notify the charge nurse of possible malabsorption.
Correct Answer: D
Rationale: An increasing abdominal girth in a child with a ventriculoperitoneal shunt may indicate malabsorption of cerebrospinal fluid, requiring immediate notification.
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.
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.
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.
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.