Exam 1: Spina Bifida Questions

A client has undergone hypophysectomy. Which action would the nurse consider to be most appropriate during postoperative care to prevent a cerebrospinal fluid (CSF) leak? 1. Prohibiting coughing or sneezing 2. Encouraging deep-breathing exercises 3. Assessing nasal drainage for quantity and quality 4. Monitoring the neurologic status for the first 24 hrs and then every 4 hrs

1 rationale: Hypophysectomy is the surgical removal of the pituitary gland and tumor for the treatment of hyperpituitarism. Coughing and sneezing should be avoided because this may lead to increased pressure in the incision area and CSF leak. Performing deep-breathing exercises would help in preventing pulmonary problems. Nasal drainage should be assessed to determine the leakage of CSF. Neurologic status of the client should be monitored to determine intracranial pressure.

A pregnant woman tells the nurse in the prenatal clinic that she knows that folic acid is very important during pregnancy and that she is taking a prescribed supplement. She asks the nurse which foods contain folic acid (folate) so she may add them to her diet in its natural form. Which foods should the nurse recommend? Select all that apply. 1. beef and fish 2. milk and cheese 3. chicken and turkey 4. black and pinto beans 5. enriched bread and pasta

4, 5 rationale: Legumes contain large amounts of folate, as do enriched grain products. Beef and fish do not contain adequate amounts of folate. Milk and cheese do not contain adequate amounts of folate; nor does fowl.

An infant with a diagnosis of hydrocephalus has just had a ventriculoperitoneal shunt inserted. In what position should the nurse place the infant? 1. supine on the unaffected side 2. side-lying on the affected side 3. head elevated at 45 degrees on the affected side 4. head elevated at 90 degrees on the unaffected side

1 rationale: Placing the infant flat will prevent complications from too-rapid reduction of intracranial fluid; placing the infant on the unaffected side will prevent pressure on the shunt valve. Placing the infant on the affected side will put pressure on the shunt valve, which may cause it to become obstructed, interfering with the outflow of cerebrospinal fluid. Raising the head of the bed will allow a too-rapid reduction in cerebrospinal fluid, which may cause the cerebral cortex to pull away from the dura, resulting in a subdural hematoma. Placing the infant on the affected side will put pressure on the shunt valve. Elevating the head to 90 degrees will permit too rapid a reduction in cerebrospinal fluid.

A nurse is assessing a newborn with a myelomeningocele. What clinical findings prompt the nurse to suspect hydrocephalus? Select all that apply. 1. tense fontanels 2. high-pitched crying 3. apgar score of less than 5 4. a defect in the lumbosacral area 5. head circumference 2 cm greater than the chest circumference

1, 2, 4 rationale: An excessive amount of cerebrospinal fluid associated with hydrocephalus causes tense fontanels. A shrill, high-pitched cry often accompanies progressive hydrocephalus and other neurologic problems. Hydrocephalus complicates approximately 80% of lumbosacral meningomyeloceles. Infants with hydrocephalus may or may not have low Apgar scores. Head circumference 2 cm greater than the chest circumference is expected in a newborn.

An infant has had surgery for repair of a myelomeningocele. For which early sign of impending hydrocephalus should the nurse monitor the infant? 1. frequent crying 2. bulging fontanels 3. change in vital signs 4. difficulty with feeding

2 rationale: After closure, spinal fluid may accumulate and reach the brain, increasing intracranial pressure (ICP) and causing the fontanels to bulge. Frequent crying may be a typical pattern for the neonate; it does not, in and of itself, indicate changes in ICP. Changes in vital signs are not among the early signs of increasing ICP in an infant. Difficulty with feeding can indicate changes in ICP but is not one of the initial signs.

During discharge planning the parents of an infant with spina bifida express concern about skin care and ask the nurse what can be done to avoid problems. What is the best response by the nurse? 1. Diapers should be changed at least every 4 hours. 2. Frequent diaper changes with cleansing are needed. 3. Medicated ointment should be applied six times a day. 4. Powder may be used in the perineal area when it becomes wet.

2 rationale: Infants with spina bifida often exhibit dribbling of urine; they need meticulous skin care and frequent diaper changes to prevent skin breakdown. Changing diapers every 4 hours is insufficient and may result in skin breakdown. Medicated ointments are unnecessary; if a skin irritation develops and an ointment becomes necessary, it should be prescribed by the healthcare provider. Powder will not keep the skin dry; when powder mixes with urine, it forms a pastelike substance that promotes skin breakdown. Also, powder is toxic if inhaled and should be avoided.

A nurse confers with the nutritionist about the diet of a 4-year-old child with spina bifida who spends many hours in a wheelchair. What should the nurse encourage the mother to increase in her child's diet? Select all that apply. 1. fat 2. fiber 3. protein 4. calories 5. carbohydrates

2, 3 rationale: Extra fiber is needed to combat constipation resulting from immobility. Extra protein is needed for maintaining muscle mass and to help prevent pressure ulcers. Of this child's dietary intake, 25% should consist of fat; this is the lowest recommended daily intake for fat. It should not be increased because more fat calories may lead to obesity in an immobilized child. Calories should be limited because energy needs are less for immobile children than for children who are active. Carbohydrates, especially simple sugars, should be limited to help prevent obesity.

The nurse teaches a pregnant client regarding the necessity for a folic acid supplement. Which neonatal disorder does folic acid taken during the first trimester prevent? 1. phenylketonuria 2. down syndrome 3. neural tube defects 4. erythroblastosis fetalis

3 rationale: A folic acid supplement (0.4 mg/day) greatly reduces the incidence of fetal neural tube defects. Phenylketonuria is a genetic disorder that cannot be prevented by the action of folic acid. Down syndrome is a genetic disorder that can also not be prevented by the action of folic acid. Erythroblastosis fetalis is related to the Rh factor and is not prevented by the action of folic acid.

All women of childbearing age are advised to include at least 400 mcg of folic acid in the daily diet to decrease the risk of neural tube defects in pregnancy. What should the nurse recommend to meet the recommendation? Select all that apply. 1. vitamin a 2. vitamin b 6 3. vitamin b 9 4. vitamin b 12 5. legumes, dark green leafy vegetables, and citrus fruits 6. eggs, meat, and poultry

3, 5 rationale: Vitamin B 9 is folic acid, and legumes, dark-green leafy vegetables, and citrus fruits are natural sources of folic acid. Most women receive adequate vitamin A in their diets, and too much may cause birth defects. Vitamin B 6 aids in metabolism conversion and the formation of red blood cells. Vitamin B 12 is associated with nerve cells and red blood cells. Eggs, meat, and poultry are sources of vitamin B 12.

The nurse is teaching a prenatal class to expectant mothers in their first trimester of pregnancy. In addition to discussing the need for 0.6 mg/day of folic acid replacement, which dietary choice that is high in folic acid should the nurse recommend? 1. one egg 2. slice of bread 3. half a cup of corn 4. half a cup of cooked spinach

4 rationale: A half of a cup of cooked spinach provides 121 to 139 mcg of folic acid per serving. One egg, a slice of bread, and half a cup of corn each provides only 20 mcg per serving.

To prevent skin breakdown on the scalp of an infant with hydrocephalus, how should the nurse position the infant? 1. on either side and flat 2. supine and trendelenburg 3. prone, with the legs elevated about 30 degrees 4. supine, with the head elevated about 45 degrees

4 rationale: The head should be elevated, allowing gravity to minimize intracranial pressure. The Trendelenburg position is contraindicated because it can increase intracranial pressure. The infant may be positioned on the back or side to allow routine changes in head position.

An infant with hydrocephalus has a ventriculoperitoneal shunt surgically inserted. What nursing care is essential during the first 24 hours after this procedure? 1. medicating the infant for pain 2. placing the infant in a high Fowler position 3. positioning the infant on the side that has the shunt 4. monitoring the infant for increasing intracranial pressure

4 rationale: The shunt may become obstructed, leading to an accumulation of cerebrospinal fluid and increased intracranial pressure. Although providing pain relief for the infant is an important part of postsurgical care, monitoring for potentially severe complications such as increased intracranial pressure takes precedence. Positioning the infant flat helps prevent complications that may result from a too-rapid reduction of intracranial fluid. The infant is positioned off the shunt to prevent pressure on the valve and incision area.

Hydrocephalus develops in an infant who was born with a meningomyelocele, and a ventriculoperitoneal shunt is inserted. What nursing intervention is most important in this infant's care during the first 24 hours after surgery? 1. placing in the high Fowler position 2. administering the prescribed sedative 3. positioning on the same side as the shunt 4. monitoring for increasing intracranial pressure

4 rationale: The shunt may become obstructed, leading to an accumulation of cerebrospinal fluid in the head; the accumulated fluid causes an increase in intracranial pressure, which in turn leads to brainstem hypoxia. Positioning the infant flat helps prevent complications resulting from too-rapid reduction of intracranial fluid. Although pain management is essential to minimize an increase in intracranial pressure, sedation is contraindicated because it will mask the infant's level of consciousness. The infant is positioned on the side opposite the shunt to prevent pressure on the valve and incision area.