my study guide
A licensed practical nurse is providing care for a child with hydrocephalus who has had a ventriculoperitoneal shunt revision. Which data collection finding should be reported to the registered nurse immediately?
Temperature 100.9° F
an infant is born with a sac protruding through the spine, containing CSF, a portion of meninges and nerve roots. the condition is referred to as
a myelomeningocele is a sac that contains a portion of the meninges, the CSF and the nerve roots
A licensed practical nurse (LPN) is bathing a neonate and notices small dark tufts of fine hair on the neonate's lower back. The LPN should take which best action?
Notify the registered nurse of the finding.
Which nursing measure is appropriate for a 2 week old infant who has a new cleft lip repair?
Place in a car seat after each feeding.
A preschooler with a history of cleft palate repair comes to the clinic for a routine well-child checkup. To determine if this child is experiencing a long-term effect of cleft palate, which question should the nurse ask?
"Is the child unresponsive when given directions?"
The nurse is providing instructions regarding home care to the parents of a 3-year-old child hospitalized with hemophilia. Which statement by a parent indicates a need for further instructions?
"It isn't safe for my child to receive the common childhood immunizations."
The parents of an infant diagnosed with pyloric stenosis ask the nurse why their child developed the disorder. Which statement should the nurse make to the parents to address their concern?
"Pyloric stenosis is caused by a structural problem and there really isn't anything you could have done to prevent it."
A baby, exhibiting no obvious signs of congestive heart failure, has been diagnosed with a small ventricular septal defect. Which of the following information should the nurse explain to the baby's parents?1. The baby will likely need open-heart surgery within a week.2. The defect will likely close without therapy.3. The defect likely developed early in the second trimester.4. The baby will likely be placed on high-calorie formula.
2. The defect will likely close without therapy.The vast majority of babies with VSDs are discharged from the well-baby nursery and are seen periodically by a cardiologist on an outpatient basis. This can be frightening to the parents who are told that their baby has a hole in his or her heart. It is important, therefore, for the nurse to reassure the parents that most VSDs do close spontaneously. However, the nurse must educate the parents regarding signs of CHF in case the baby does begin to go into cardiac failure.
A baby with myelomeningocele is admitted to the neonatal intensive care unit. Which of the following signs/symptoms would the nurse expect to see?1. Hyperreflexia2. Ptosis3. Bilateral lower limb paralysis4. Marked respiratory distress
3. Bilateral lower limb paralysis
The nurse has provided dietary instructions to the mother of a child with celiac disease. The nurse determines that the mother understands the instructions when the mother states to include which food in the child's diet?
Corn
The nurse is doing discharge teaching with a client diagnosed with sickle cell disease. The nurse instructs the client to avoid which situations that could precipitate a sickle cell crisis? Select all that apply.
DehydrationExposure to infectionHigh altitudes
The nurse is reviewing the laboratory results of an infant suspected of having hypertrophic pyloric stenosis. Which result should the nurse most likely expect to note?
Elevated blood pH
Parent-infant bonding for an infant with meningomyelocele prior to repair can be enhanced by:
Encouraging the parents to talk to and touch the baby.
A 3-year-old child is seen in the health care clinic, and a diagnosis of encopresis is made. The nurse reviews the record, expecting to note which of the following that is a sign of this disorder?
Evidence of soiled clothing
After a discussion with the health care provider, the parents of an infant with patent ductus arteriosus (PDA) ask the nurse to explain once again what PDA is. How should the nurse respond?
It is a connection between the pulmonary artery and the aorta.
An infant with Tetralogy of Fallot becomes cyanotic and dyspneic after a crying episode. In what position should the nurse place the infant to relieve the cyanosis and dyspnea?
Knee-chest
A nurse is obtaining a health history from the parents of a preschooler with celiac disease. What characteristic does the nurse expect when the parents describe their child's stools?
Large, pale, foul-smelling
A mother reports feeding her infant immediately before arriving in the emergency department. After completing the assessment, the nurse reports which finding immediately to the health care provider because it likely indicates pyloric stenosis?
Peristaltic waves that traverse the epigastrium
A child with cerebral palsy (CP) is working to achieve maximum potential for locomotion, self-care, and socialization in school. The nurse would work with the child to meet these goals by:
Placing the child on a wheeled scooter board
What is the priority nursing intervention for an infant with a myelomeningocele before surgical correction?
Preventing trauma to the sac
A nurse is assisting a health care provider (HCP) during the examination of an infant with hip dysplasia. The HCP performs the Ortolani maneuver. Which of the following best describes the action/purpose of the Ortolani maneuver?
Reducing the dislocated femoral head back into the acetabulum
The nurse is caring for a newborn diagnosed with Down syndrome. The parents are asking questions about the disorder. The nurse should provide which information when discussing Down syndrome?
The condition is congenital and results in moderate to severe retardation and has been linked to an extra chromosome 21 (group G).
A nurse provides instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which instruction provided by the nurse is accurate?
The harness needs to be removed to check the skin and for bathing
A nurse is concerned about helping the parents of an infant with cerebral palsy set long-term goals for the family. These goals should be set with the understanding that:
Unknown extent of the disability requires continual adjustments
A nurse is assigned to care for a child with a spica cast. Which action should be avoided when caring for the child?
Using pillows to elevate the head and shoulders
A 6-week-old infant is brought to the clinic by the parents. The mother states that the baby has been vomiting with increasing frequency and force after feeding. Hypertrophic pyloric stenosis (HPS) is diagnosed by the practitioner. What clinical findings of HPS does the nurse expect to identify? (Select all that apply.)
White vomitusPeristaltic wavesInsatiable hunger
The parents of an infant who has undergone surgical repair of a myelomeningocele express concern about skin care and ask what they can do to prevent problems. What should the nurse teach the parents about their infant's skin care?
Will require long-term multidisciplinary follow-up care
After surgery for pyloric stenosis, the nurse could anticipate that the infant will:
be fed clear liquids within 6 hours.
Which statement best describes pseudohypertrophic (Duchenne) muscular dystrophy (DMD)?
c) DMD is characterized by muscle weakness, usually beginning at about age 3 years.
Given knowledge of muscular dystrophy, the nurse would expect to see which form of this condition most commonly in children? a) Limb-girdle b) Becker's c) Myotonic d) Duchenne's
d)Duchenne'sExplanation: Duchenne's accounts for 50% of all cases of muscular dystrophy.
which of the following would be included in the plan of care for a hospitalized newborn following surgical repair of a myelomeningocele. select all that apply
daily head circumference measurements are done to assess for hydrocephalus.diagnostic tests include MRI scan, CT scan, ultrasound and myelography
The nurse in a newborn nursery is told that a newborn with spina bifida (myelomeningocele type) will be transported from the delivery room. The nurse is asked to prepare for the arrival of the newborn. The nurse places which priority item at the newborn's bedside?
A bottle of sterile normal saline
A 3-year-old child is status post shunt revision for hydrocephaly. Part of the discharge teaching plan for the parents is signs of shunt malformation. Which signs are of shunt malformation? (Select all that apply.)A. Personality changeB. Bulging anterior fontanelC. VomitingD. DizzinessE. Fever
ANS: A-C-EPersonality change can be a sign of shunt malformation related to increased intracranial pressure.Vomiting can be a sign of shunt malformation related to increased intracranial pressure.Fever can be a sign of shunt malformation and is a very serious complication.The anterior fontanel closes between 12-18 months of age.Dizziness is difficult to assess in a 3-year-old and is not necessarily a sign of shunt malformation.
A pregnant woman asks about prenatal diagnosis of hydrocephalus. The nurses response should be based on which knowledge?a. It can be diagnosed only after birth.b. It can be diagnosed by chromosome studies.c. It can be diagnosed with fetal ultrasonography.d. It can be diagnosed by measuring the lecithin-to-sphingomyelin ratio.
ANS: CHydrocephalus can be diagnosed by fetal ultrasonography as early as 14 weeks of gestation. Most incidents of hydrocephalus are not chromosomal in origin. The lecithin-to-sphingomyelin ratio can be used to determine fetal lung maturity.
A nurse is caring for an infant with a myelomeningocele. What does the nurse expect this infant to have that it is different from an infant with a meningocele?
Affected lower extremities
A month-old-infant is admitted to the pediatric unit after 3 days of vomiting. Hypertrophic pyloric stenosis (HPS) is diagnosed. The nurse performs a physical assessment and obtains a health history from the mother. What continual assessments are necessary to determine the infant's immediate needs? Select all that apply.
Amount and color of last voidingSkin turgor and respiratory status
The nurse is reviewing the laboratory test results for an infant suspected of having hypertrophic pyloric stenosis. The nurse should expect to note which value as the most likely laboratory finding in this infant?
Blood pH of 7.50
A nurse is caring for an infant with hydrocephalus after the insertion of a shunt. How should the nurse evaluate the effectiveness of the shunt?
By palpating the anterior fontanel
The nurse is creating a teaching plan for the parents of an infant with a ventricular peritoneal shunt who will be discharged from the hospital. Which instruction should the nurse include in the plan of care?
Call the health care provider if the infant has a high-pitched cry.
The nurse is caring for a child recently diagnosed with cerebral palsy. The parents of the child ask the nurse about the disorder. The nurse bases the response to the parents on the understanding that cerebral palsy is best described by which statement?
Cerebral palsy is a chronic disability characterized by a difficulty in controlling the muscles.
At the age of 3 weeks an infant undergoes surgery to repair a cleft lip. What should postoperative nursing care include?
Cleansing the suture line to prevent infection
A 12-month-old child has just returned from the recovery room after a palatoplasty. The nurse performs an assessment and determines that which finding requires further intervention and indicates a need for follow-up?
Clove-hitch restraints are secured to the arms.
A 3-week-old infant who has been vomiting for 3 days is admitted to the pediatric unit with a diagnosis of hypertrophic pyloric stenosis. What essential information should the nurse identify during the admission procedure?
Respiratory status, amount and appearance of last voiding
You are caring for a child with hydrocephalus who is post-operative from a shunt revision. Which assessment finding is your priority for increased intracranial pressure?A. Nausea and refusal to eat postoperatively B. Complaint of a headacheC. Irritability and wanting to sleepD. Decrease in HR over the last hour
ANS: D
The nurse is developing a plan of care for a 5-week-old infant being admitted with hypertrophic pyloric stenosis who is scheduled for pyloromyotomy. In the preoperative period, the nurse should place the infant in which best position?
In an infant seat placed in the crib
The mother of a 2-week-old infant who is going to have a cleft lip repair asks if she will be able to hold her baby after surgery. The nurse should reply:
"Holding your baby helps keep her content."
The clinic nurse provides instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which statement made by one of the parents indicates an understanding of the use of the harness?
"I can remove the harness to bathe my infant."
A nurse provides information to the mother of a 2-week-old infant who was diagnosed with clubfoot at the time of birth. Which statement by the mother indicates the need for further instruction regarding this disorder?
"I need to bring my child back to the clinic in 1 month for a new cast."
The nurse provides home care instructions to the mother of a child who had a cleft palate repair 4 days ago. Which statement by the mother indicates the need for further instruction?
"I need to buy some straws for drinking."
The parents of a neonate born with a cleft lip ask a nurse when the cleft lip will be repaired. What is the best response by the nurse?
"Usually before the baby is 12 weeks old."
The nurse is assigned to care for a child with a diagnosis of atrial septal defect. The nurse plans care knowing that which description is characteristic of this type of defect? Select all that apply.
. Right atrial and ventricular enlargement occurs.2. Signs and symptoms of decreased cardiac output may occur.4. It is an opening between the two atria and allows oxygenated and unoxygenated blood to mix.
The health care provider is assessing a 2-year-old child for the presence of celiac disease. For what specific signs and symptoms should the nurse be alert? (Select all that apply.)
1 steatorrhea, 4 distended abdomen, 5 iron deficiency anemia
A nurse is reviewing the results of a genetic analysis performed on a child with Duchenne muscular dystrophy (DMD). Which of the following results would the nurse expect to see? . 1. 46 XY, X-linked recessive inheritance... 2. 46 XX, autosomal dominant inheritance. 3. 46 XY, autosomal recessive inheritance. 4. 46 XX, mitochondrial inheritance
1. 46 XY, X-linked recessive inheritance
The nurse is caring for a 3-year-old child with suspected bacterial meningitis. Which signs/symptoms should the nurse expect to find during the initial assessment? Select all that apply.
1. Fever2. Irritability3. Nuchal ridigidty
A nurse notes that a child is exhibiting signs of cerebral palsy. At what age are these signs usually first noticeable?
12 mos
A nurse suspects that a newly delivered baby has Down syndrome. The nurse noted that the baby exhibited which of the following physiological characteristics? Select all that apply.1. . Elongated face. 2. Protruding tongue. 3. Large, high-set ears. 4. Wide, flat nasal bridge. 5. Asymmetric Moro reflex
2,4
A 2-year-old child with developmental dysplasia of the hip has a spica cast applied. The mother asks the nurse how to keep the cast clean. How should the nurse respond?
2-"place plastic wrap or duct tape around the perineal edges of the cast."
The nurse is caring for a child with a diagnosis of atrioventricular canal defect. The nurse plans care knowing that the child will experience which characteristics of this disorder? Select all that apply.
2. Crying-induced cyanosis 3. Mild to moderate heart failure5. The mixing of oxygenated and unoxygenated blood
A couple is being discharged from the hospital with their 2-day-old Down syndrome baby. The nurse is providing discharge teaching. The nurse should include in the teaching information regarding which of the following physiological characteristics of the syndrome?1. Small cerebral ventricles2. Weak musculature3. Inability to feel pain4. Low glomerular filtration rate
2. Weak musculatureThe nurse should educate the parents regarding the child's weak musculature because the child will be at high risk for a number of problems, including upper respiratory infections, pendulous abdominal muscles, and lumbering gait.
A nurse is teaching a mother how to care for her toddler who is in a spica cast. In what position should the nurse suggest that the mother place the toddler during a feeding?
3-semi-Fowler on a passed, adjustable tilt board
The parents of a child recently diagnosed with cerebral palsy ask the nurse about the disorder. The nurse bases the response on the understanding that cerebral palsy is which type of condition?
A chronic disability characterized by impaired muscle movement and posture
The nurse is measuring the head circumference of an infant on the fifth postoperative day after surgical placement of a ventricular peritoneal shunt for the correction of hydrocephalus. The nurse notes that the head circumference measurement has increased by 1 cm over the past 24 hours. The nurse analyzes this assessment data as which expectation after this surgical procedure?
A complication related to the functioning of the shunt
The postop nursing care of an infant who has had a cheiloplasty includes (select all that apply):
Apply elbow restraintsProvide pain relief measures
A nurse is caring for an infant with hypertrophic pyloric stenosis. A pyloromyotomy is scheduled. Which pathophysiological modification must be addressed before this surgery can be performed safely?
Fluid and electrolyte imbalances must be corrected.
A nurse in the pediatric clinic is reviewing the health history of a 6-year-old child with celiac disease who has been on the dietary regimen for 6 months. What evaluation criterion does the nurse use to assess the child's adherence to the diet?
Formed Bowel movements
An infant who has undergone surgical correction of a myelomeningocele is to be discharged. What information should the nurse include when preparing the parents to care for their infant at home?
How to perform range-of-motion exercises for the lower extremities
The nurse in the hospital is giving at-home feeding instructions to a family whose child is being discharged after being born with a cleft lip. Which statement by the mother would indicate that further teaching is indicated?
I must always feed my baby with a syringe and not use a nipple."
The nurse is caring for a child who experienced a head injury. The nurse is monitoring the child for signs of increased intracranial pressure (ICP) and informs the mother about the measures to monitor for and prevent increased ICP. Which statement by the mother would indicate a need for further teaching?
I will encourage my child to drink plenty of fluids
The nurse is creating a plan of care for a newborn diagnosed with bilateral club feet. Which information should the nurse plan to include in the parents education?
If casting is needed, it will begin at birth and continue for 12 weeks, at which time the condition will be reevaluated.
The nurse provides home care instructions to a mother of an infant who has had a surgical procedure to insert a ventriculoperitoneal shunt. Which statement by the mother indicates an understanding of the complications associated with this surgical procedure?
If my infant develops a high-pitched cry, i should call my health care provider
A 2 week old infant will be fitted with a Pavlik harness as treatment for developmental hip dysplasia. The mother asks the nurse about the harness and how it will help her baby. To reinforce the physician's explanation, the nurse should teach the mother that:
Keeping the hip bone within the hip socket helps the socket to become deeper.
A nurse is caring for an infant who just underwent surgery for a cleft lip. In which position should the nurse place the infant?
Low Fowler
An infant with a cleft lip and palate is admitted to the hospital for surgical repair. Place the nurse's postoperative interventions in order of priority.
Maintaining a patent airwayPrevent Vomiting Monitoring parenteral fluid infusionsTeaching the parents alternate feeding methodsAssessing the infant's hearing status
A child is admitted to the pediatric unit with a diagnosis of celiac disease. Based on this diagnosis, the nurse expects that the child's stools will have which characteristic?
Malodorous
Which is the primary goal that should be included in the plan of care for a child who has cerebral palsy?
Maximize the child's assets and minimize the limitations.
The nurse is reviewing the primary health care provider's prescriptions for a child admitted to the hospital with a diagnosis of sickle cell crisis. The nurse should contact the primary health care provider if what intervention is prescribed?
Meperidine hydrochloride
A nurse is caring for an infant who has just undergone myelomeningocele repair. What should the nursing plan of care include?
Monitoring for cerebrospinal fluid leakage
The nurse is assigned to care for a child diagnosed with hemophilia. When reviewing the results of the prescribed laboratory tests, which test should the nurse anticipate to be abnormal?
PTT
The nurse is preparing to discharge a toddler newly diagnosed with hemophilia. What instruction should be included in the teaching plan for home care of this child?
Padding crib rails and table corners
The nurse is assisting with data collection from an infant who has been diagnosed with hydrocephalus. If the infant's level of consciousness diminishes, which is a priority intervention?
Palpating the anterior fontanel
To prepare a school-aged child with cerebral palsy (CP) for school, the nurse should establish goals to help the child achieve maximum potential for locomotion, self-care, and socialization. What action will assist the nurse in achieving these goals?
Placing the child on a wheeled scooter board or similar device to allow independent movement
Before surgical repair, the usual position of a newborn with a meningomyelocele is:
Prone, maintaining abduction with a pad between the legs.
Which nursing assessment suggest infection of an episiotomy?
Redness of the perineum with separation of the suture line.
The parents of a child with a cleft palate are concerned and ask the nurse when the palate will be repaired. The nurse should plan to base the response on which information about cleft palate repair?
Repair usually is performed between 6 months and 2 years.
he nurse is caring for a child after cleft palate repair. To reduce the risk of aspiration after feeding the child, what is the best position for the nurse to place the child in?
Right side in semi-Fowler's
The nurse is assisting in the care of a child who underwent a surgical repair of a cleft lip the previous day. Which nursing action should the nurse implement when caring for the surgical incision?
Rinse the incision with sterile water after using prescribed solution.
The nurse is assigned to care for an infant on the first postoperative day after a surgical repair of a cleft lip. Which nursing intervention is appropriate when caring for this child's surgical incision?
Rinsing the incision with sterile water after feeding
A nurse is caring for an infant after a cleft lip repair. Which item should the nurse use to feed the infant for several days after the surgery?
Rubber-tipped syringe
Positioning and vomiting
Side lying, Hob elevated
While performing care of an infant with hypertrophic pyloric stenosis (HPS) the nurse observes visible peristaltic waves. What other sign of HPS should the nurse expect?
Small mass in the right upper quadrant
The nurse is caring for a child with a ventricular septal defect, and the parents ask the nurse about the treatment for this disorder. On what information should the nurse base the response?
Some defects may close spontaneously.
After a cleft lip repair, the nurse instructs the parents about cleaning of the lip repair site. The nurse should plan to use which solution when demonstrating this procedure to the parents?
Sterile water
The nurse is admitting a 12-month-old child diagnosed with iron deficiency anemia. Which assessment finding should the nurse expect to note in this child?
Tachycardia
A home care nurse visits a child with a diagnosis of celiac disease. Which finding best indicates that a gluten-free diet is being maintained and has been effective?
The child is free of diarrhea.
A nurse is providing information to the family of a child about a synthetic cast that has been applied to the child for the treatment of a clubfoot. Which information should the nurse provide to the mother?
The synthetic cast allows for greater mobility than a plaster cast.
An infant is found to have communicating hydrocephalus. The parents ask for clarification of the health care provider's explanation of the problem. How should the nurse respond?
There is a part of the brain surface that usually absorbs spinal fluid after its production that is not functioning adequately."
The parents of an infant with pyloric stenosis ask a nurse many questions about the problem. What information should the nurse communicate when answering these questions?
This is a condition with an excellent prognosis.
A 3-year-old has cerebral palsy (CP) and is hospitalized for orthopedic surgery. The child's mother states the child has difficulty swallowing and cannot hold a utensil to self-feed. The child is slightly underweight for height. What is the most appropriate nursing action related to feeding?
b) Stabilize the child's jaw with one hand (either from a front or side position) to facilitate swallowing.
What is important when caring for a child with myelomeningocele in the preoperative stage?
d) Measure the head circumference and examine the fontanels for signs that might indicate developing hydrocephalus.
A woman who is 6 weeks pregnant tells the nurse that she is worried her baby might have spina bifida because of a family history. What should the nurse's response be based on?
d) The concentration of α-fetoprotein in amniotic fluid can potentially indicate the presence of the defect prenatally
The nurse is caring for a hospitalized infant and is monitoring for increased intracranial pressure (ICP). The nurse notes that the anterior fontanel bulges when the infant cries. Based on this assessment finding, which action should the nurse take?
document the finding
The pathologic disturbance of pyloric stenosis results from:
hypertrophy of the pyloric muscle
The nurse is caring for an infant diagnosed with hydrocephalus. Which manifestation should the nurse interpret as the earliest finding of increased intracranial pressure (ICP)?
irritability
The nurse is preparing a plan of care for an infant who will be returning from the recovery room following the surgical repair of a cleft lip located on the right side of the lip. On return from the recovery room, the nurse should plan to place the infant in which position?
left lateral position
Celiac disease is at increased risk for
lymphoma
toddler who has undergone cleft palate repair is now able to tolerate fluids. What should the nurse use to offer the toddler fluids?1
small cup
A nursing student is asked to discuss the topic of clubfoot at a clinical conference. The student plans to tell the group that clubfoot:
Is a congenital anomaly
A child with a fractured femur is placed in Buck's skin traction and the nurse is planning care for the client. Which information about this type of traction is correct?
Is a type of skin traction that pulls the hip and leg into extension
The home care nurse is instructing the mother of a child diagnosed with iron deficiency anemia regarding the administration of a liquid oral iron supplement. Which statement, if made by the mother, indicates an understanding of the administration of this medication?
"I will use a medicine dropper to place the iron near the back of the throat."
A pediatric nurse is having a discussion with a father whose child has recently been diagnosed with spastic cerebral palsy. Which of the following statements by the nurse is appropriate?1. "It must be very hard to know that your child's ability to move will decrease over time."2. "I am sure that it is hard for you to know that your child has this disease, but at least the medicine will treat the underlying problem."3. "The treatment plan for your child will focus on enabling him to have as normal movements as possible."4. "The nerve stimulation of your child's legs will enable him to walk on his own when he is older."
3. "The treatment plan for your child will focus on enabling him to have as normal movements as possible."The signs and symptoms of CP result from a hypoxic insult to the brain. The therapeutic interventions are aimed at enabling the child to reach his or her highest potential.
The nurse is admitting a newly delivered neonate with meningocele into the nursery. Which of the following assessments is priority for the nurse to perform?1. Assessment of the red reflexes2. Hard palate assessment3. Trunk incurvation reflex4. Head and chest circumferences
4. Head and chest circumferencesOver 90% of babies born with meningocele and myelomeningocele will also have hydrocephalus. It is priority, therefore, for the nurse to assess the circumferences to determine whether the baby is suffering from that complication.
A baby is admitted to the neonatal intensive care unit following closure of a myelomeningocele. Which of the following patient care goals should the nurse include in the nursing care plan? The baby will:1. maintain supine positioning.2. have normal elimination patterns.3. exhibit a normal startle reflex.4. consume feedings and gain weight.
4. consume feedings and gain weight.Patient-care goals are expectations of patients' behavior. A baby with a meningomyelocele would not be expected to have normal elimination patterns or a normal startle (Moro) reflex because of the nerve damage sustained from the defect. In addition, to prevent injury to the surgical site, the baby must be placed in the prone position. After surgery, the baby would be expected to feed and gain weight.
The parents of a newborn with a cleft lip are concerned and ask the nurse when the lip will be repaired. With which statement should the nurse respond?
Cleft-lip repair is usually performed during the first weeks of life.
The nurse is preparing to admit a 6-month-old infant with increased intracranial pressure (ICP). What clinical manifestations should the nurse expect to observe in this infant? (Select all that apply.)a. High-pitched cryb. Poor feedingc. Setting-sun signd. Sunken fontanel
ANS: A, B, C, EClinical manifestations of increased ICP in an infant include a high-pitched cry, poor feeding, setting-sun sign, and distended scalp veins. The infant would have a tense, bulging fontanel and an increased head circumference.
The nurse is discussing long-term care with the parents of a child who has a ventriculoperitoneal shunt to correct hydrocephalus. An important part of the discussion with the parents is thatA. parental protection is essential until the child reaches adulthood.B. mental retardation is to be expected with hydrocephalus.C. shunt malfunction or infection requires immediate treatment.D. most usual childhood activities must be restricted.
ANS: CBecause of the potentially severe sequelae, symptoms of shunt malfunction or infection must be assessed and treated immediately if present.Limits should be appropriate to the child's developmental age. Except for contact sports, the child will have few restrictions.The development of mental retardation depends on the extent of damage before the shunt was placed.Limits should be appropriate to the child's developmental age. Except for contact sports, the child will have few restrictions.
A child is admitted for revision of a ventriculoperitoneal shunt for noncommunicating hydrocephalus. What is a common reason for elective revision of this shunt?a. Meningitisb. Gastrointestinal upsetc. Hydrocephalus resolutiond. Growth of the child since the initial shunting
ANS: DAn elective revision of a ventriculoperitoneal shunt would most likely be done to accommodate the childs growth. Meningitis would require an emergent replacement or revision of the shunt. Gastrointestinal upset alone would not indicate the need for shunt revision. Noncommunicating hydrocephalus will not resolve without surgical intervention.
A mother arrives at the emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected, and a nurse is monitoring the child continuously for signs of increased intracranial pressure (ICP). Which of the following is a late sign of increased ICP in this child?
Bradycardia
nursing student is preparing to conduct a clinical conference regarding cerebral palsy. Which characteristic related to this disorder should the student plan to include in the discussion?
Cerebral palsy is a chronic disability characterized by difficulty with muscle control.
A 2-year-old toddler has just returned from surgery where a hip spica cast was applied. Which nursing action will best maintain the child's skin integrity?
Changing the toddler's diapers every 2 hours.
The nurse is caring for a newborn with a diagnosis of spina bifida (myelomeningocele). Which should the nurse perform to monitor for a major symptom of this condition?
Check for responses to painful stimuli from the torso downward.
An infant diagnosed with spina bifida cystica (meningomyelocele type) has had the sac surgically removed. The nurse plans which intervention in the postoperative period to maintain the infant's safety?
Elevating the head with the infant in the prone position
A child is hospitalized with a diagnosis of atrial septal defect. The nurse plans care knowing that what are the characteristics of this type of defect? Select all that apply.
It's a L to R heart shuntOxygenated and unoxygenated blood mixLeft side of the heart is experiencing higher pressure than the right side.
The nurse is caring for a newborn with spina bifida (myelomeningocele type) who is scheduled for the removal of the gibbus (sac on the back filled with cerebrospinal fluid, meninges, and some of the spinal cord). Which is the priority nursing action in the preoperative period?
Maintain moisture of the normal saline dressing on the gibbus area.
The nurse is caring for a child with celiac disease. According to the mother, the child has experienced a poor appetite for the past few months. Which assessment finding supports poor nutritional intake?
Muscle wasting in the extremities
The nurse is monitoring an infant for signs of increased intracranial pressure (ICP) and notes that the anterior fontanel bulges when the infant is sleeping. Based on this finding, which is the priority nursing action?
Notify the registered nurse.
The nurse is caring for an infant after a pyloromyotomy is performed to treat hypertrophic pyloric stenosis. In which position should the nurse place the infant after surgery?
Prone with the head of the bed elevated
The nurse is developing a plan of care for a child diagnosed with hemophilia. Which evaluative statement developed by the nurse indicates a positive outcome for this specific child?
The child experiences no long-term complications from injury or bleeding.
The nurse is providing discharge instructions to the mother of a child who had a cleft palate repair. Which statement should the nurse make to the mother?
You need to use an orthodontic nipple on the child's bottle."
What is considered a mixed cardiac defect?a) Pulmonic stenosisb) Atrial septal defectc) Patent ductus arteriosusd) Transposition of the great arteries
d) Transposition of the great arteries
Surgical repair for patent ductus arteriosus (PDA) is done to prevent the complication of
d) increased pulmonary vascular congestion.
The nurse is caring for a child with increased intracranial pressure (ICP). What interventions should the nurse plan for this child? (Select all that apply.)a. Avoid jarring the bed.b. Keep the room brightly lit.c. Keep the bed in a flat position.d. Administer prescribed stool softeners.e. Administer a prescribed antiemetic for nausea
ANS: A, D, EOther measures to relieve discomfort for a child with ICP include providing a quiet, dimly lit environment; limiting visitors; preventing any sudden, jarring movement, such as banging into the bed; and preventing an increase in ICP. The latter is most effectively achieved by proper positioning and prevention of straining, such as during coughing, vomiting, or defecating. An antiemetic should be administered to prevent vomiting, and stool softeners should be prescribed to prevent straining with bowel movements. The head of the bed should be elevated 15 to 30 degrees.
The nurse is providing instructions to a parent of a 10-year-old child diagnosed with hemophilia regarding appropriate activities. The nurse tells the mother that which activity should be safe for the child to participate in?
Archery
The nurse is developing a plan of care for a newborn infant with spina bifida (meningomyelocele type). The nurse includes assessment measures in the plan to monitor for increased intracranial pressure (ICP). Which assessment technique should be performed to detect the presence of an increase in ICP?
Assessing the anterior fontanel for bulging
An infant is seen in a clinic and is diagnosed with unilateral hip dysplasia. Which finding is associated with this condition?
Asymmetry of the gluteal skin folds when the infant is placed prone and the legs are extended against the examining table
A 7-month-old child has been diagnosed with cerebral palsy (CP). Which of the following signs/ symptoms would the nurse assess as consistent with the diagnosis?. 1. Positive grasp reflex, .2. Pigeon chest 3. Harlequin sign 4. Circumoral cyanosis
1. Positive grasp reflexIn healthy babies, the neonatal grasp reflex begins to fade at about 3 months of age and is replaced by a voluntary grasp by about 5 months of age. A grasp reflex that does not fade is consistent with a diagnosis of CP.
Which statement should the nurse include when providing safety instructions to the parents of an infant with a diagnosis of hydrocephalus?
"When picking up your infant, support the infant's neck and head with the open palm of your hand."
The parents of an infant born with a myelomeningocele are confused about what the primary healthcare provider has told them about the condition. What should the nurse consider before answering the parents' questions in language that they will understand?
A saclike cyst of meninges, containing a portion of spinal cord and fluid, is protruding through a defect in the spine.
A nurse is assigned to care for a child with hypertrophic pyloric stenosis who is scheduled for pyloromyotomy. Which of the following positions would the nurse place the child in during the preoperative period?
Prone with the head of the bed elevated
After surgery for repair of a myelomeningocele, the nurse places the infant in a side-lying position with the head slightly elevated. What is the main reason the nurse places the infant in this position after this particular surgery?
To reduce intracranial pressure
A nurse is caring for an infant with developmental dysplasia of the hip (DDH). Based on the nurse's knowledge of DDH, which clinical manifestation should the nurse expect to observe?Select all that apply.
c) Asymmetric thigh and gluteal foldsd) Positive Ortolani and Barlow testse) Shortening of limb on affected side
Following a cleft lip repair, the nurse provides instructions to the parents regarding cleaning of the lip repair site. Which of the following solutions would the nurse use in demonstrating this procedure to the parents?
sterile water
The nurse is caring for a 1-year-old child after cleft palate repair. On completion of feeding, the nurse should plan for which appropriate nursing action?
Rinsing the mouth with water
A 6-year-old child is admitted for revision of a ventriculoperitoneal shunt for noncommunicating hydrocephalus. What sign or symptom does the child have that indicates a revision is necessary?a. Tachycardiab. Gastrointestinal upsetc. Hypotensiond. Alteration in level of consciousness
ANS: DIn older children, who are usually admitted to the hospital for elective or emergency shunt revision, the most valuable indicators of increasing intracranial pressure are an alteration in the childs level of consciousness, complaint of headache, and changes in interaction with the environment.
A nurse is planning to evaluate the vomitus of an infant with pyloric stenosis. Why does the nurse anticipate that the vomitus will be white rather than bile-stained?
There is an obstruction above the opening of the common bile duct.
An infant is seen in the health care provider's office for complaints of projectile vomiting after feeding. Findings indicate that the child is fussy and is gaining weight but seems never to get enough to eat. Pyloric stenosis is suspected. Which prescription would the nurse anticipate having the highest priority in the care of this child?
Prepare the family for surgery for the child.
Cerebral palsy (CP) may result from a variety of causes. It is now known that the most common cause of CP isa) birth asphyxiab) neonatal diseasesc) cerebral traumad) prenatal brain abnormalities
d) prenatal brain abnormalities
Congenital heart defects have traditionally been divided into acyanotic or cyanotic defects. Based on the nurse's knowledge of congenital heart defects, this system in clinical practice is
d) problematic, because children with acyanotic heart defects may develop cyanosis.
A nurse reviews the record of a 1-year-old child seen in the clinic and notes that the health care provider has documented a diagnosis of celiac crisis. Which of the following symptoms would the nurse expect to note in this condition?
profuse watery diarrhea
The nurse is planning care for an infant who has a diagnosis of hypertrophic pyloric stenosis and is scheduled for surgery. Which intervention should the nurse include to meet the infant's preoperative needs?
Monitor the intravenous (IV) infusion, intake, output, and weight.
A nurse is educating the parents of a child with an atrial septal defect regarding the child's condition. Which of the following information would be appropriate for the nurse to provide?1. The baby becomes cyanotic because the blood is flowing through a hole from the right side of the heart to the left side of the heart.2. The baby has a murmur because there is a hole between the aorta and the pulmonary artery.3. The baby's heart is working harder than a normal heart because some of its blood is reentering the pulmonary system.4. The baby's heart rate is slowed because of the high number of red blood cells in the blood.
3. The baby's heart is working harder than a normal heart because some of its blood is reentering the pulmonary system.This response is correct. In the case of an ASD and other acyanotic defects, the blood is reentering the pulmonary system as a result of left to right shunting.Left-to-right shunt refers to the path the blood takes through the heart. When there is a hole in the heart—ASD, VSD, or PDA—the blood travels from the left side to the right side simply because the left ventricle is stronger than the right ventricle. Because the blood travels repeatedly into the right ventricle, it enters the pulmonary system repeatedly via the pulmonary artery. In some cyanotic diseases, most notably Tetralogy of Fallot, the blood travels from the right side of the heart to the left side. This occurs in Tetralogy of Fallot because the stenotic pulmonic valve prevents the blood from entering the pulmonary artery. Rather the blood is "shunted" through the overriding aorta, thereby bypassing the lungs.
