Deck 27: Nursing Care of the Child Born With a Physical or Developmental Difference

Question 1

The nurse is caring for an infant born with a myelomeningocele. Which should the nurse assess in this patient?

A) Vision
B) Level of pain
C) Voiding pattern
D) Tonic neck reflex

Answer 1

Voiding pattern

Question 2

A newborn with esophageal atresia has just returned from surgery to place a gastrostomy tube. Which nursing diagnosis will the nurse use to plan the care for this patient?

A) Risk for imbalanced nutrition
B) Risk for deficient fluid volume
C) Risk for impaired skin integrity
D) Risk for ineffective gas exchange

Answer 2

Risk for impaired skin integrity

Question 3

The nurse manager at a family clinic is identifying ways to address the 2020 National Health Goals for the prevention of birth defects. Which action should the manager encourage all staff to perform when caring for pregnant patients?

A) Avoid extreme physical activity and exercise.
B) Monitor daily intake of calcium and dairy products.
C) Stress the importance of taking prenatal folic acid as prescribed.
D) Ensure adequate hydration by drinking eight glasses of water each day.

Answer 3

Stress the importance of taking prenatal folic acid as prescribed.

Question 4

The nurse is evaluating the outcome of teaching for a baby born with torticollis. Which observation indicates that teaching has been successful?

A) The child looks in the direction of the affected muscle.
B) The child's shoulder of the affected muscle is elevated.
C) The child looks in the direction opposite of the affected muscle.
D) The child rolls onto the side to look from the direction opposite of the affected muscle.

Question 5

A newborn is diagnosed with a meconium plug. Which interventions should the nurse prepare to provide to help resolve this health problem? (Select all that apply.)

A) Administration of a barium enema
B) Administration of a gastrografin enema
C) Administration of 5 ml of saline enema
D) Administration of 10 ml of tap water enema
E) Rectal instillation of acetylcysteine (Mucomyst)

Question 6

The nurse is assessing a 2-week-old infant who developed hydrocephalus. What should the nurse expect to assess in this patient?

A) Excessive thirst
B) A soft, fretful cry
C) Hypothermia in the late afternoon
D) White sclera showing above the pupils

Question 7

An infant with hydrocephalus has a ventriculoperitoneal shunt inserted. Immediately following the procedure, which nursing action would best prevent decompression from excessive CSF flow?

A) Elevating the infant's head 60 degrees
B) Keeping the head of the infant level with the body
C) Avoiding exercising the upper extremities during bathing
D) Positioning the infant with the head dependent to the body

Question 8

The nurse is preparing teaching for the parents of a newborn with a newly placed ventriculoperitoneal shunt. What should the nurse include in this teaching? (Select all that apply.)

A) Restrict the intake of fruit, vegetables, and fluid.
B) Expect to have the shunt replaced as the child grows.
C) Examine the site every day for signs of swelling or redness.
D) Notify the health care provider if the child develops a fever.
E) Observe the child for signs of increased intracranial pressure.

Question 9

The nurse is checking a newborn for the presence of Ortolani and Barlow signs. For which health problem are these assessments used?

A) Club foot
B) Cleft palate
C) Hip dysplasia
D) Tracheoesophageal fistula

Question 10

A newborn is scheduled for casting to correct a talipes disorder. What should the nurse instruct the parents about the height of the cast?

A) To the calf
B) Above the knee
C) At the level of the hip
D) Above the level of the waist

Question 11

The nurse is planning care for a newborn with a cleft lip and palate scheduled for surgery in a few weeks. For which health need will the nurse focus when planning this patient's care?

A) Visual stimulation
B) Nutritional support
C) Prevention of pneumonia
D) Prevention of oral infection

Question 12

The nurse is evaluating a mother's ability to catheterize her 2-year-old son. Which observations indicate that teaching has been effective? (Select all that apply.)

A) Mother washes hands using warm, soapy water.
B) Mother coats the tip of the catheter with petroleum jelly.
C) Mother quickly removes the catheter once urine stops flowing.
D) Mother inserts the catheter into the urinary meatus one half of an inch.
E) Mother washes around the child's urinary meatus with warm, soapy water.

Question 13

An infant is prescribed oxybutynin chloride (Ditropan) for neurogenic bladder. What should the nurse instruct the parents about this medication?

A) This medication has no adverse effects.
B) Check the child frequently for sweating.
C) Schedule appointments with the health care provider when necessary.
D) Provide the child with the medication when urinary output is sluggish.

Question 14

What health teaching should the nurse provide to the parents of a child recovering from surgery to repair a cleft palate?

A) The child can expect to have chronic maxillary pain.
B) The child may have increased episodes of otitis media.
C) The child will have difficulty sensing the temperature of food.
D) The child may have a poor appetite from a decreased sense of taste.

Question 15

The nurse is caring for a baby with esophageal atresia. Which situation during the mother's pregnancy indicates that this health problem was developing?

A) Hydramnios
B) Oligohydramnios
C) A difficult second stage of labor
D) Bleeding at 32 weeks of pregnancy