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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.
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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.
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 assessment madThe nurse is caring for a macrosomic newborn of a woman diagnosed with gestational diabetes immediately after birth.e by the nurse would lead the nurse to suspect hip dysplasia?
- A. Asymmetrical gluteal folds
- B. Limited adduction of the affected side
- C. Foot turned inward
- D. Deep inguinal creases
Correct Answer: A
Rationale: Asymmetrical gluteal folds indicate hip dysplasia due to the femur slipping out of the acetabulum.
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.
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.