Maternity CH 21

The nurse is teaching the caregivers of an infant diagnosed with hypospadias how to properly care for the infant. The nurse determines the session is successful when the caregivers make which statement?

"Being able to most likely correct this in one stage rather than several is reassuring."

The nurse is assessing a 4-year-old male born with a heart condition who is brought in for a routine well-child visit by his parents. The parents report he is very curious, active, and very social; however, they often see him take breaks in his play by squatting for a few minutes or sitting on the sidelines at which time they insist he take a nap. Assessment reveals a child small for his age, mildly cyanotic, and tires easily. What is the best response to the parents when they ask the nurse for suggestions on how to encourage their son to take the naps they insist on but he doesn't want to take?

"Children are often aware of their limitations, and because he has shown that he knows when he needs to take a break he should be encouraged to control his own activity level."

The nurse is working with an adult female who has PKU and desires to become pregnant. The nurse notes on her assessment her current serum phenylalanine level is 10 mg/dl. Which instruction should the nurse prioritize for this client?

"It will be best if you cut back on meat, fish, and dairy products before you become pregnant to get your serum phenylalanine level down under 8 mg."

The nurse is answering questions from the parents of a newborn diagnosed with clubfoot (congenital talipes equinovarus). When asked by the parents which treatment will be used, what would the nurse predict?

Application of a splint or cast

The parents of a newborn are struggling with the news that their infant has spina bifida. Which technique should the nurse prioritize teaching to the parents that will help increase the infant's comfort and development?

Cuddle the baby in a chest-to-chest position.

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.

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.

A 2-year old child has gone home following successful hip dysplasia surgery in a spica cast. Her caregiver calls 2 days later to report the child has been vomiting after eating, but has no fever. Which response should the nurse prioritize in response to this caregiver?

If there is no fever and the child wants to eat, the cast may be too tight; she should be brought back in for recasting."

A caregiver brings a 13-year-old male for a pre-high school checkup and reports he has spent lots of time in the principal's office or serving detention during junior high, and questions if he is too immature to be in high school. The nurse's assessment reveals evident breasts, little underarm or chest hair, and a high-pitched voice. Which condition should the nurse suspect and discuss with the primary care provider?

Klinefelter syndrome

The nurse is preparing pre- and postoperative instructions for a family whose 6-month-old infant is scheduled for an initial surgical repair of a cleft lip and palate. Which activity should the nurse prioritize in the instructions to the caregivers of this infant?

Let the infant become accustomed to being in elbow restraints.

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

A nurse is providing postoperative care to an infant who had a ventriculoarterial shunt placed. Approximately 8 hours after surgery, the nurse notes on assessment shrill crying and projective vomiting. Which response should the nurse prioritize at this time?

Notify the primary care provider immediately.

A nursing instructor is leading a group discussion on congenital hydrocephalus. The instructor determines the session is successful after the students correctly choose which factor that determines the noncommunicating type?

Obstruction that keeps CSF from passing between the ventricles and the spinal cord

The nurse is monitoring a new mother changing her newborn's diaper and notices a musty smell to the infant's urine. Which condition should the nurse prioritize in further assessments to rule out?

Phenylketonuria

The nurse is preparing a nursing care plan for an infant who was born with spina bifida with myelomeningocele. Which nursing goal should the nurse prioritize for this child?

Preventing infection

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 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.

The nurse is preparing to teach the young parents of a newborn who is diagnosed with spinal bifida occulta how to care for their newborn. Which information should the nurse prioritize when explaining this defect?

There is a bony defect that occurs without soft-tissue involvement.

A nurse is providing information for a pregnant woman who has just discovered that the fetus she's carrying is likely to have Down syndrome. Which statement by the nurse is most accurate regarding the possible concerns for a child with Down syndrome?

They have a higher risk of developing leukemia than those in the general population.

The nursing instructor is teaching a session on techniques that the nursing students can use to properly address concerns of parents with children who are born with a cleft lip and palate. The instructor determines the session is successful when the students correctly choose which nursing intervention as being the most effective in these situations?

Use reflective listening with nonjudgmental support.

The nurse is assessing a group of infants and notes one of the infants has chronic constipation and an enlarged abdomen. The nurse would determine this infant is showing indications of which condition?

congenital hypothyroidism

The nurse is caring for a newborn diagnosed with a diaphragmatic hernia. The nurse will prepare to teach the parents concerning which potential treatment modality?

immediate surgery to correct

The parents of an infant diagnosed with phenylketonuria are not sure they agree with the diagnosis and proposed treatment. The nurse should point out that this condition can result in which additional condition if left untreated?

intellectual disability

The nurse is preparing to assess an infant who is diagnosed with a ventricular septal defect. Which assessment finding should the nurse be prepared to document?

loud, harsh murmur

The nurse is providing care for a child following a cardiac catheterization. Which nursing action should the nurse prioritize during the first 12 hours after the procedure?

observing the site and extremity