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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.
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The nurse is obtaining intake information on a new patient being seen for preconception care and notes a family history of neural tube defectsW. hat interventions can the nurse suggest to this woman to help prevent neural tube anomalies in a developing fetus?
- A. Avoid drug use.
- B. Follow a low-calorie, low-protein diet.
- C. Take a folic acid supplement every day.
- D. Exercise daily.
- E. Maintain bed rest during the first trimester.
Correct Answer: A,C
Rationale: Avoiding drug use and taking a daily folic acid supplement (0.4 mg) until the 12th week of pregnancy reduces the risk of neural tube defects.
What is the most appropriate response?
- A. Cystic fibrosis is a chromosomal defect.'
- B. Cystic fibrosis is a metabolic defect.'
- C. Cystic fibrosis is a malformation present at birth.'
- D. Cystic fibrosis is a blood disorder.'
Correct Answer: B
Rationale: Cystic fibrosis is an inborn error of metabolism due to a deficiency of an enzyme necessary for cell metabolism.
The home health nurse is educating parents on home phototherapy. What will the nurse include when providing information to these parents?
- A. Cover the infant's eyes when under the light.
- B. Use a three-prong plug.
- C. Keep a diaper in place.
- D. Place the light source on an absorbent surface.
- E. Expose as much skin as possible.
Correct Answer: B,C,E
Rationale: Home phototherapy instructions include using a three-prong plug, keeping a diaper in place, and exposing as much skin as possible; the light source should be on a nonabsorbent surface, and eyes do not need covering.
What should the nurse assess for with this neonate?
- A. Hypoglycemia
- B. Erythroblastosis fetalis
- C. Intracranial hemorrhage
- D. Pancreatic failure
Correct Answer: A
Rationale: The newborn of a mother with diabetes is prone to hypoglycemia due to hyperinsulinism after the abrupt loss of maternal glucose.
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.