NUR 353 Exam 3 | Answered with Rationales

NUR 353 Exam 3 | Answered with Rationales | Answered with Rationales What should the plan of care for a newborn with hypospadias include? 1 Preparing the infant for insertion of a cystostomy tube 2 Explaining to the pa ...

NUR 353 Exam 3 | Answered with Rationales | Answered with Rationales What should the plan of care for a newborn with hypospadias include? 1 Preparing the infant for insertion of a cystostomy tube 2 Explaining to the parents the genetic basis for the defect 3 Keeping the infant's penis wrapped with petrolatum gauze 4 Giving the parents reasons why circumcision should not be performed -The parents need to know why circumcision should not be performed. The foreskin may be needed for repair and reconstruction of the penis. A cystostomy tube is not inserted, because there is no interference with voiding. Hypospadias is not a genetic disorder, although there appears to be some evidence that it is familial. The penis is generally wrapped in petrolatum gauze after, not before, surgical correction of hypospadias. The day after undergoing abdominal appendectomy a school-aged child is prepared for ambulation. Which nursing action would be most effective before the start of ambulation? 1 Providing a rest period 2 Offering a reward for walking 3 Encouraging use of the spirometer 4 Administering the prescribed pain medication After several episodes of abdominal pain and vomiting, a 5-month-old infant is admitted with a tentative diagnosis of intussusception. What assessment should the nurse document that will aid confirmation of the diagnosis? After several episodes of abdominal pain and vomiting, a 5-month-old infant is admitted with a tentative diagnosis of intussusception. What assessment should the nurse document that will aid confirmation of the diagnosis? 1 Frequency of crying 2 Amount of oral intake 3 Characteristics of stools 4 Absence of bowel sounds -Because intussusception creates intestinal obstruction in which the intestine "telescopes" and becomes trapped, passage of intestinal contents is lessened; stools are red and look like currant jelly because of the mixing of stool with blood and mucus. bowel sounds are not affected Before discharging a 9-year-old child who is being treated for acute poststreptococcal glomerulonephritis (APSGN), what information should the nurse plan to give the parents? 1 How to obtain the vital signs daily 2 Date on which to return to prepare for renal dialysis 3 Instructions about which high-sodium foods to avoid 4 List of activities that will encourage the child to remain active -Sodium is usually limited to control or prevent edema or hypertension until the child is asymptomatic. The child is usually on a regular diet with sodium restrictions (e.g., salty snacks [potato chips, pretzels, tortilla chips] and hot dogs, bacon, bologna, and other processed meats). child should rest and not be active An infant with congenital hypothyroidism receives levothyroxine for three months. During the return appointment, which statement by the mother indicates to the nurse that the drug is effective? 1 The infant is alert and interactive. 2 The skin is cool to the touch. 3 The baby's fine tremor has ceased. 4 The baby's thyroid stimulating hormone level has increased. -Infants with congenital hypothyroidism are lethargic and may even need to be awakened and stimulated to nurse; therefore, an infant who is alert and interacts appropriately for its age would demonstrate improvement. At the beginning of the first formula feeding a newborn begins to cough and choke, and the lips become cyanotic. What is the nurse's priority action in response to this situation? 1 Stimulate crying 2 Substitute sterile water for the formula 3 Suction and then oxygenate the newborn 4 Stop the feeding momentarily and then restart it - Cyanosis, choking, and coughing are signs of aspiration and hypoxia. Suctioning and oxygenation are needed. Crying may add to the distress. Water could be aspirated, worsening the problem. Stopping the feeding momentarily and then restarting it is unsafe; the newborn is showing signs of a blocked airway. 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 -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. What is the priority of preoperative nursing care for an infant with a cleft lip? 1 Preventing crying 2 Modifying feeding 3 Preventing infection 4 Minimizing handling -difficulty sucking on a nipple. cleft pallat=infection, not lip The mother of an infant who just underwent cleft lip repair tells the nurse, "He seems restless. May I hold him?" What information influences the nurse's response? 1 Holding may meet needs and reduce tension on the suture line. 2 Sedation limits activity and decreases tension on the suture line. 3 Handling may increase irritability, causing tension on the suture line. 4 Arm movements cannot be controlled, placing tension on the suture line. -Touching and cuddling provide a sense of well-being and relieve strain on the suture line that results from restlessness and crying. It is inappropriate to sedate an infant for its calming effect or to decrease activity. Careful handling will not damage the suture line. Arm movement can be controlled by applying elbow restraints to prevent the infant's hands from touching the suture line. A 1-month-old infant is admitted to the pediatric unit with a tentative diagnosis of Hirschsprung disease (congenital aganglionic megacolon). What procedure does the nurse expect to be used to confirm the diagnosis? 1 Colonoscopy 2 Rectal biopsy 3 Multiple saline enemas 4 Fiberoptic nasoenteric tube A child with hip dysplasia has undergone a closed reduction surgery. The nurse assesses the child 2 days after the surgery and feels that the treatment and care provided for the child were not effective. The nurse made this conclusion based on what findings? 1 The child has a staggering gait. 2 The child is unable to walk independently. 3 The child has impaired muscle tone and flexibility. 4 The child's femoral head did not return to the hip socket -If the laboratory reports indicate that the femoral head did not return to the hip socket, it implies that the surgery was ineffective and useless. Normal for child to have staggering gait, pain and lose muscle tone / flexibility Which nursing action should be included in the plan of care for a child with acute poststreptococcal glomerulonephritis? 1 Encouraging fluids 2 Monitoring for seizures 3 Measuring abdominal girth 4 Checking for pupillary reactions -Cerebral edema from hypertension or cerebral ischemia may occur, which may result in seizures. Increasing fluid intake may lead to an increase in blood pressure and edema. Measuring abdominal girth is appropriate for children with nephrotic syndrome, in which the child has hypoalbuminemia that causes fluid to shift from plasma to the abdominal cavity. Glomerulonephritis will not alter pupillary reactions. An infant who has undergone surgery for hypertrophic pyloric stenosis (HPS) is being bottle fed by the mother. What should the nurse teach the mother about feedings to decrease the chance of the infant vomiting? 1 Start with small, frequent feedings. 2 Rock for 20 minutes after a feeding. 3 Keep the infant awake for 30 minutes after feeding. 4 Position the infant flat on the right side during feedings Starting with small feedings will decrease the risk of vomiting. Rocking, keeping the infant awake, and positioning the infant horizontally all increase the chance of vomiting. A client is admitted to the hospital with a head injury sustained while playing soccer. For which early sign of increased intracranial pressure should the nurse monitor this client? 1 Nausea 2 Lethargy 3 Sunset eyes 4 Hyperthermia Lethargy is an early sign of a changing level of consciousness; changing level of consciousness is one of the first signs of increased intracranial pressure. Nausea is a subjective symptom, not a sign, that may be present with increased intracranial pressure. Sunset eyes are a late sign of increased intracranial pressure that occur in children with hydrocephalus. Hyperthermia is a late sign of increased intracranial pressure that occurs as compression of the brainstem increases. A 3-year-old child with mild iron deficiency anemia is seen by a nurse in the clinic. In addition to weakness and fatigue, what should the nurse expect the child to exhibit? 1 Cold, clammy skin 2 Increased pulse rate 3 Increased blood pressure 4 Cyanosis of the nail beds Increased pulse rate (tachycardia) occurs as the body tries to compensate for hypoxia due to mild iron deficiency anemia. Severe anemia however can manifest as pale, cool, and clammy skin. Increased blood pressure is not a response associated with anemia. Cyanosis of the nail beds is a sign of carbon monoxide poisoning. A 2½-year-old toddler is admitted with a fever of 103° F (39.4° C), stiffness of the neck, and general malaise. The diagnosis is acute bacterial meningitis. What is the priority nursing intervention for this child? 1 Increasing fluids 2 Administering oxygen 3 Giving a tepid sponge bath 4 Instituting droplet precautions Droplet precautions prevent the spread of infection to others; isolation is a priority and should be implemented immediately. There is no indication that the child is dehydrated; fluid maintenance is a continuing goal. There is no indication that the child needs oxygen. Oxygen is not given routinely; it is given if the child has a decreased oxygen saturation level. A sponge bath is not given because these children are sensitive to stimuli, and movement causes increased discomfort. An 8-year-old child is being discharged after recovery from a sickle cell vaso-occlusive (painful crisis) episode. The nurse teaches the parents the do's and don'ts of the child's care. What statement by the parents satisfies the nurse that they understand the principles of care? 1 Have the child schooled by a private tutor 2 Restrict the child's fluid intake during the night 3 Permit the child to play with just one peer at a time 4 Encourage the child to engage in low-intensity activities low intense bec strenuous activities = increased cellular metabolism, tissue hypxia, sickling. dont restruct fluids, fluids prevent sickling A young child from a developing country is admitted to the pediatric unit for surgery to correct a congenital heart defect. The mother asks the nurse why her child squats after exertion. The nurse responds, in language that the mother understands, that this position does what? 1 Decreases the number of muscle aches 2 Improves walking capacity and hip mobility 3 Reduces how hard the heart must work 4 Helps more blood return to the heart When the child squats, blood pools in the lower extremities because of hip and knee flexion which causes less blood to return to the heart and reduces how hard the heart must work (cardiac workload). For this young child, squatting after exertion does not reduce muscle aches, it is unrelated to walking capacity and hip mobility, and it decreases (not increases) blood return to the heart. An 11-year-old child with juvenile idiopathic arthritis will be receiving continued nonsteroidal antiinflammatory drug (NSAID) therapy at home. Which important toxic effect of NSAIDs must be included in the nurse's discharge instructions to the child and family? 1 Diarrhea 2 Hypothermia 3 Blood in the urine 4 Increased irritability Hematuria may result from the use of NSAIDs because they may cause nephrotoxicity. Diarrhea can occur but is not a sign of toxicity. Hypothermia does not occur with NSAIDs. Drowsiness, not hyperactivity, may occur. Which explanation should the nurse consider when formulating a response to a client's inquiry about intussusception of the bowel? 1 Kinking of the bowel onto itself 2 A band of connective tissue compressing the bowel 3 Telescoping of a proximal loop of bowel into a distal loop 4 A protrusion of an organ or part of an organ through the wall that contains it Intussusception is the telescoping or prolapse of a segment of the bowel into the lumen of an immediately connecting segment of the bowel. Volvulus is a twisting of the bowel onto itself. Adhesions are bands of scar tissue that can compress the bowel. Herniation describes protrusion of an organ through the wall that contains it. A nurse is caring for a 3-week-old infant with hypertrophic pyloric stenosis who is severely dehydrated. What finding does the nurse expect when assessing the infant? 1 Weight loss of 5% 2 Severe allergic reactions 3 Depressed anterior fontanel 4 Urine specific gravity of 1.014 Depressed fontanels related to decreased cerebral spinal fluid are a classic sign of fluid volume deficiency in infants. A 5% weight loss indicates mild dehydration; a severely dehydrated infant will have a 15% weight deficit. Dehydration is unrelated to allergic reactions. This specific gravity is within the expected limits of 1.005 to 1.020. Which of these age groups has the highest incidence of lead poisoning? 1 Adult 2 Toddler 3 Adolescent 4 School-age child An infant who has a congenital heart defect with left-to-right shunting of blood is admitted to the pediatric unit. What early sign of heart failure should the nurse identify? 1 Cyanosis 2 Restlessness 3 Decreased heart rate 4 Increased respiratory rate Because the lungs are stressed by pulmonary edema, a quicker respiratory rate is the first and most reliable indicator of early heart failure in infants. Cyanosis is a late sign of heart failure; with early failure there is still adequate perfusion of blood. Infants with early heart failure do not move about; they become fatigued quickly, especially when feeding, because of a decrease of oxygen to body cells. The heart rate of an infant in early heart failure increases, not decreases, in an attempt to increase oxygen to body cells. While performing preoperative teaching a nurse explores a young adolescent's concern about changes in appearance after surgery to correct scoliosis. What is the most appropriate statement by the nurse? 1 "After surgery your back will be much straighter." 2 "You're concerned about how you'll look after surgery." 3 "Many teenagers who have this type of surgery do very well." 4 "Your parents think it's important for you to have this surgery." Which are sources of lead the nurse should assess for when providing care to a toddler-age client who is admitted with lead poisoning? Select all that apply. 1 Water 2 Pottery 3 Stained glass 4 Collectable toys 5 Vinyl miniblinds A nurse provides dietary instruction to a client who has iron deficiency anemia. Which food choices by the client does the nurse consider most desirable? Select all that apply. 1 Raw carrots 2 Boiled spinach 3 Dried apricots 4 Brussels sprouts 5 Asparagus spears the food sources highest in iron are, "Liver and muscle meats, dried fruits (apricots), legumes, dark green leafy vegetables (spinach), whole-grain and enriched bread and cereals, and beans." Although carrots, Brussels sprouts, and asparagus spears contain some iron, they are not considered high sources of iron. A toddler is found to have coarctation of the aorta. What does the nurse expect to identify when taking the child's vital signs? 1 Irregular heartbeat 2 Weak femoral pulse 3 Thready radial pulses 4 Increased temperature Coarctation of the aorta is a narrowing of the aorta, usually in the thoracic segment, resulting in decreased blood flow below the constriction and increased blood volume above it. The femoral pulses are weak or absent. An irregular heartbeat and increased temperature are not related to coarctation of the aorta. The radial pulses are bounding in coarctation of the aorta. A 3-month-old infant with tetralogy of Fallot is admitted for a diagnostic workup in preparation for corrective surgery. The morning after cardiac catheterization the infant suddenly becomes cyanotic and begins breathing rapidly. In what position should the nurse immediately place the infant? 1 Supine 2 Lateral 3 Knee-chest 4 Semi-Fowler The knee-chest position decreases venous return from the legs, which increases systemic vascular resistance, thereby increasing pulmonary blood flow. The parent of a child with hemophilia asks the nurse, "If my son hurts himself, is it all right if I give him two baby aspirins?" What is the best response by the nurse? 1 "You seem concerned about giving drugs to your child."