A nurse is planning care for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac ? Which of the following interventions should the nurse include in the plan of care? a. Initiate contact precautions . b. Provide a latex - free environment c. Limit visitors t...
PEDS 4 (GU, Musculoskeletal ,
Neuromuscular) Review Questions and
Correct Answers
A nurse is planning care for an infant who has spina bifida and is to undergo surgical
closure of the myelomeningocele sac ? Which of the following interventions should the
nurse include in the plan of care?
a. Initiate contact precautions .
b. Provide a latex - free environment
c. Limit visitors to immediate family members .
d. Maintain the infant in the supine position . ✅Provide a latex - free environment
Children who have spina bifida have a very high risk for developing a latex allergy ,
which can be life - threatening . The specific cause is unknown . However , because the
incidence of latex allergy increases with repeated exposure to latex products , it is
critical for the nurse to eliminate every possible exposure to supplies and equipment
that contain latex .
Which of the following should the nurse do first when caring for an infant who just had a
repair of a myelomeningocele ?
a. Offer clear liquids
b. Measure head circumference
c. Weight diapers for 24 - hour urine output
c. Assess for infection ✅Measure head circumference
Which is the priority nursing intervention for an unconscious child after a fall ?
a. Determine weather a neck injury is present .
b. Establish adequate airway Respiratory effectiveness is the primary concern in the
care of the unconscious child .
c. Monitor intracranial pressure
dPerform neurologic assessment ✅Establish adequate airway
Which clinical manifestations in an infant would be suggestive of spinal muscular
atrophy ( SMA ) as so known as Werdnig - Hoffmann disease?
a. motor deficits on one side of the body
b. Hyperactive deep tendon reflexes
c. Weak cry and difficulty breathing
d. Hypertonicity ✅Weak cry and difficulty breathing
Hypertonicity An infant that has difficulty breathing and a weak cry , along with other
signs of hypotonia may suggest spinal muscular atrophy . The deep tendon reflexes are
, absent . The child has hypotonia and inactivity as the most prominent features . The
motor deficits are bilateral .
Which assessment findings should the nurse note in a school - age child with Duchenne
muscular dystrophy ( DMD ) ? ( Select all that applies )
a. Lordosis
b. Gower sign
c. Spastic muscles
d. Kyphosis
e. Waddling gait ✅Waddling gait, gower sign, lordosis
Difficulties in running , riding a bicycle , and climbing stairs are usually the first
symptoms noted in Duchenne muscular dystrophy. Typically, affected boys have a
waddling gait and fall frequently and develop a characteristic manner of rising from a
squatting or sitting position on the floor ( Gower sign ) . Lordosis occurs as a result of
weakened pelvic muscles , and the waddling gait is a result of weakness in the gluteus
medius and maximus muscles . Kyphosis and scoliosis are not assessment findings
with DMD .
The parents of a child with cerebral palsy ask the nurse whether any drugs can
decrease their child's spasticity. The nurse's response should be based on which
statement?
Medications that would be useful in reducing spasticity are too toxic for use with children
.
Many different medications can be highly effective in controlling spasticity .
Anticonvulsant medications are sometimes useful for controlling spasticity .
Implantation of a pump to deliver medication into the intrathecal space to decrease
spasticity has recently become available ✅Implantation of a pump to deliver
medication into the intrathecal space to decrease spasticity has recently become
available .
The nurse is teaching a group of nursing students about a newborns born with spina
bifida which is congenital defect . Which common problem is associated with this defect
?
Cognitive impairment
Neurogenic bladder
Cranioschisis
Respiratory compromise ✅Neurogenic bladder
The nurse is preparing to admit a newborn with myelomeningocele to the neonatal
intensive care nursery . Which describes this newborn's defect ?
Hernial protrution of a saclike cyst of meninges with spinal fluids but no neural element .
Fissure in the spinal column that leaves the meninges and the spinal cord
Herniation of the brain and meninges through a defect in the skull
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