PREP U_CHAP 27

The nurse is caring for an infant in a hip spica cast. Which nursing intervention would the nurse prioritize to promote skin integrity?

Give daily sponge baths and clean around the edges of the cast.

The parent of a child with a ventriculoperitoneal shunt calls the nurse saying that the child has a temperature of 101.2°F (38.4°C), a blood pressure of 108/68 mm Hg, and a pulse of 100 beats/min. The child is lethargic and vomited the night before. Other children in the family have had similar symptoms. Which nursing intervention is most appropriate?

Have the parent bring the child to the primary health care provider's office.

The nurse is assessing a newborn and suspects developmental dysplasia of the hip (DDH). For which sign is the nurse prioritizing in this potential diagnosis?

Limited abduction of the affected hip

Which environmental consideration is most helpful to promoting comfort when the neonate is withdrawing from alcohol and drugs?

Provide a dark, quiet environment

A nursing student has read that cleft lip is diagnosed at birth based on inspection of physical appearance and that cleft palate is diagnosed by which method?

feeling the palate with a gloved finger or using a tongue blade

The nurse caring for a newborn observes a cleft lip and palate. The parent plans to bottle-feed the newborn. Which instruction will the nurse include when teaching the parent about feeding this newborn?

how to use special cleft palate nipples when feeding

A nursing student is learning about congenital disorders in newborns and correctly associates the causes for central nervous system defects to be which factors? Select all that apply.

imbalanced cerebrospinal fluid malformation of the neural tube during embryonic development

When caring for a neonate born with a myelomeningocele, which complication is the nurse's priority to monitor for during the first 12 hours of life?

infection risk

In the infant born with a cleft lip and a cleft palate, the highest priority of the nurse is related to which intervention?

maintaining the nutritional needs of the infant

What triad of characteristics are found in the infant with Pierre Robin sequence?

micrognathia, cleft palate, and glossoptosis

A mother is inspecting her newborn and notices the baby has a sixth finger. The nurse would explain that this condition is called:

polydactyly.

A nurse is caring for a newborn with a repaired cleft lip. What intervention can the nurse provide to facilitate drainage of mucus and secretions to prevent aspiration?

position the child on side

The nurse is monitoring a newborn who exhibited a large head at birth and is exhibiting an increasing head growth on continued assessment. Which additional findings on assessment should lead the nurse to suspect hydrocephalus in this infant?

Eyes appear to be pushed downward.

During the newborn examination, the nurse notes that an infant who is appropriate for gestational age by birth weight has a head circumference below the 10th percentile and the fontanels (fontanelles) are not palpable. What action would the nurse take?

Report the findings to the pediatric health care provider

Which nursing action is required when caring for the post-term infant?

Serial blood glucose levels

The nurse is caring for a preterm infant and notes frothing and excessive drooling. Which additional assessment finding should the nurse prioritize and report immediately?

Severe cyanosis

The nurse is screening an expectant mother for the extent of current substance use. Which statement made by the mother is most concerning?

Since I have learned that I am pregnant, I have only binged a few times."

The nurse is assessing the neonate shown. From the assessment, the nurse notes that there is paralysis of the lower extremities. For which condition does the nurse anticipate performing care?

Spina bifida with myelomeningocele

The nurse is caring for a newborn who is large-for-gestational-age (LGA). Which characteristics are documented as a contributing factor? Select all that apply.

The mother has had previous large-for-gestational-age neonates. The mother has poorly controlled diabetes. Both parents are of a larger stature and size.

The community health nurse is preparing a presentation which will illustrate the various forms of spina bifida for a health fair. Which explanation should the nurse use to explain spina bifida with meningocele?

The spinal meninges protrude through the bony defect and form a cystic sac.

A nursing student is caring for a newborn with a defect in the neural arch where the posterior laminae of the vertebrae have failed to close. The nurse knows that this infant is suffering from which disorder?

spina bifida

small dimple on the sacral area

spina bifida occulta

Following surgery for an imperforated anus, care of the infant should include which nursing intervention? Select all that apply.

stool softener clean suture line side-lying position

When assisting in the delivery of a postterm baby, as soon as the baby's head is delivered, the nurse is most likely to be called upon to help the physician perform what action?

suction the baby's mouth and nose

In examining her newborn son, a mother becomes concerned that the frenulum, under his tongue, is too short. She points it out to the nurse. What should the nurse say in response to this mother's concern?

"In most cases, it doesn't cause problems with breastfeeding but it may need to be corrected."

A nurse is teaching the parents of a child who has been diagnosed with spina bifida. Which statement by the nurse would be the most accurate description of spina bifida

"Its presence indicates that many areas of the central nervous system (CNS) may not develop or function adequately."

The nurse is completing accurate output on a preterm client. The nurse changed the client's diaper, which weighs 50 g. The dry diaper weighs 22 g. Which amount does the nurse record under output? Record your answer using a whole number.

28

A new mother is concerned because she fears that her infant's head is larger than normal. What would be the nurse's best response?

A large head at birth in itself is not indicative of hydrocephalus, but we will keep a check on it.

Which health care provider assessment technique does the nurse anticipate being used to determine developmental dysplasia of the hip (DDH) on a newborn?

Barlow sign and Ortolani click

The nurse is assessing the plantar creases on the newborns for documentation on the Ballard Scale. Which documentation is interpreted as evidence of a full-term infant?

Creases covering two-thirds of the anterior foot

Which types of play are most appropriate for the 3-month-old who is in an orthopedic cast?

Mobiles and rattles

Which congenital condition is an immediate emergency requiring notification of the health care provider?

Tracheoesophageal fistula

immediate emergency

Tracheoesophageal fistula

A newborn boy is diagnosed with esophageal atresia and tracheoesophageal fistula. After the nurse provides preoperative teaching, which statement indicates that the parents need additional teaching?

We can probably start feeding him with the bottle about a day after the surgery."

In the infant diagnosed with spina bifida with myelomeningocele, the infant will likely have:

a partial to complete paralysis in the lower extremities.

The nurse is reviewing the medical record of the antepartum client with an abnormal maternal serum alpha-fetoprotein test. The mother is distraught and states, "How bad can it be?" The nurse is correct to describe which?

a type of spina bifida

The priority for the nurse caring for a newborn with esophageal atresia is to observe for which finding?

aspiration

In the child diagnosed with hydrocephalus, an obstruction occurs that blocks the normal process of:

cerebrospinal fluid.

A nurse is caring for a newborn who was diagnosed with an imperforate anus. Assessment reveals drooling, copious bubbles of mucus in mouth, rattling respirations, and abdominal distention. During feeding, the newborn coughs and becomes cyanotic. Which action by the nurse would be appropriate?

clear the airway

In the hour immediately following the birth of an infant with a physical challenge, what is a nursing care priority? Select all that apply.

determining the infant's immediate physiologic needs promoting bonding between parents and the newborn

At which point is the treatment Rho(D) immune globulin for hemolytic disease of the newborn finished?

during the postpartum period

A nurse in the newborn nursery has noticed that an infant is frothing and appears to have excessive drooling. Further assessment reveals that the baby has episodes of respiratory distress with choking and cyanosis. What disorder should the nurse suspect based on these findings?

esophageal atresia

The nurse observes a newborn experiencing coughing, choking, and unexplained cyanosis during feeding. These are classic signs of what condition?

esophageal atresia

A nurse is teaching the parents of an infant diagnosed with meningomyelocele how to perform intermittent clean urinary catheterization. The nurse determines that the teaching was successful when the parents state that they will perform the catheterization at which frequency?

every 4 hours

Which actions should nurses advocate to help the nation achieve the 2020 National Health Goals? Select all that apply.

teaching about folic acid supplementation prior to conception obtaining early prenatal care providing support after the diagnosis of a fetal disorder

The nurse in the newborn nursery is providing shift handoff on a neonate with hydrocephalus. Prior to ventriculoperitoneal shunting, which assessment findings are most important to be communicated? Select all that apply.

type of cry head circumference status of fontanels (fontanelles) projectile vomiting

A nurse is caring for an infant newly diagnosed with spina bifida occulta. The infant's parent is crying stating, "My child will have physical disabilities." Which statement by the nurse is appropriate?

"This is the mildest form and there may be no deficits seen."

Which clinical manifestation is seen in the child with hydrocephalus?

An extremely large and rapidly growing head

Immediately after birth, the nurse is caring for a newborn with a myelomeningocele. What intervention should the nurse provide to prevent drying out of the sac to avoid damage?

Apply a sterile dressing moistened in a warm, sterile saline solution.

When caring for a newborn, the nurse observes regurgitation of feedings and abdominal distension. The nurse suspects tracheoesophageal fistula. Which of the following interventions should the nurse implement based on this suspicion?

Arrange for suction equipment and an oxygen source.

The nurse is completing the newborn assessment in the nursery. The nurse notes that the newborn's feet have an unusual foot position. How will the nurse assess the significance of this position?

Attempt to straighten the feet to the midline position.

In completing the newborn assessment checklist, the nurse documents a meconium stool. This documentation rules out which condition?

Imperforate anus

Upon shift handoff the nurse reports meconium staining of the amniotic fluid. Which neonatal system requires close monitoring by the incoming nurse?

respiratory system

Which diagnostic measure is most accurate in detecting neural tube defects?

significant level of maternal serum alpha-fetoprotein present in amniotic fluid