Exam 3 Flashcards
A 6-month-old infant is brought to the clinic with concerns of increasing irritability, poor feeding, and a rapid increase in head circumference. On physical examination, the nurse observes bulging fontanelles, dilated scalp veins, and a setting-sun sign (downward deviation of the eyes). A diagnosis of hydrocephalus is made, and the infant is scheduled for a ventriculoperitoneal (VP) shunt placement.
What clinical manifestations are hallmark signs of hydrocephalus in this infant?
Select all that apply (SATA):
- Bulging fontanelles
- Dilated scalp veins
- Setting-sun sign
- Clubfoot
- Hypoglycemia
- Bulging fontanelles
- Dilated scalp veins
- Setting-sun sign
Option 1: Bulging fontanelles are a hallmark sign of increased intracranial pressure (ICP) in infants due to hydrocephalus.
* Option 2: Dilated scalp veins occur as a result of increased ICP and impaired cerebrospinal fluid drainage.
* Option 3: The setting-sun sign is a classic sign of hydrocephalus, where the eyes deviate downward, exposing the sclera above the iris.
* Option 4: Clubfoot is unrelated to hydrocephalus.
* Option 5: Hypoglycemia is not a characteristic finding in hydrocephalus.
A child has undergone ventriculoperitoneal (VP) shunt placement for hydrocephalus. The nurse is monitoring the child in the post-operative period. Which assessment finding should the nurse prioritize?
A. Abdominal distention
B. Mild headache
C. Decreased appetite
D. Restlessness during sleep
A. Abdominal distention
Rationale: VP shunts drain excess cerebrospinal fluid into the peritoneal cavity. Abdominal distention may indicate complications such as peritonitis or malfunction of the shunt, requiring immediate intervention.
A 3-year-old child is admitted for observation following VP shunt placement for hydrocephalus. The nurse notes the following findings during the night shift: elevated temperature of 101.5°F (38.6°C), irritability, redness along the surgical site, and a poor response to pain relief measures.
What is the priority action by the nurse?
A. Administer prescribed antipyretics and monitor temperature
B. Notify the healthcare provider immediately
C. Document the findings and recheck in 1 hour
D. Encourage the parents to comfort the child
B. Notify the healthcare provider immediately
Rationale: The symptoms of fever, irritability, redness at the surgical site, and poor pain control may indicate shunt infection or malfunction, which are serious complications requiring immediate medical evaluation.
A newborn is diagnosed with a myelomeningocele at the lumbosacral region. Which complication is the infant at greatest risk for prior to surgery?
A. Hypoglycemia
B. Pulmonary hypertension
C. Cardiomyopathy
D. Meningitis
D. Meningitis
Meningitis is a significant risk in infants with a myelomeningocele due to the exposed spinal cord and meninges, which leave the central nervous system vulnerable to infection.
The nurse is caring for an infant with a myelomeningocele awaiting surgery. What are priority nursing interventions during this time?
Select all that apply:
- Position the infant in a prone position.
- Cover the defect with a sterile, moist, non-adherent dressing.
- Monitor the infant for signs of infection.
- Begin active range-of-motion exercises for the lower extremities.
- Perform regular diaper changes to prevent soiling the defect.
- Position the infant in a prone position.
- Cover the defect with a sterile, moist, non-adherent dressing.
- Monitor the infant for signs of infection.
A 4-day-old infant underwent surgery for myelomeningocele repair. The nurse is conducting a post-operative assessment. Which finding requires immediate intervention?
A. Temperature of 98.6°F (37°C)
B. Bulging anterior fontanelle
C. Slight redness at the surgical site
D. Sleeping 2-3 hours between feedings
B. Bulging anterior fontanelle
Rationale: A bulging anterior fontanelle is a sign of increased intracranial pressure, which may indicate hydrocephalus—a common complication after myelomeningocele repair.
When describing a myelomeningocele defect to the parents of an affected newborn, how should the nurse explain it?
A. “It is a herniation of the spinal cord, meninges, and cerebrospinal fluid through an opening in the vertebral column.”
B. “It is a complete closure of the spinal cord but with abnormal neural tissue development.”
C. “It is an isolated defect of the vertebrae that does not involve the spinal cord.”
D. “It is a failure of the brain and skull to develop properly.”
A. “It is a herniation of the spinal cord, meninges, and cerebrospinal fluid through an opening in the vertebral column.”
Rationale: A myelomeningocele is characterized by the protrusion of the spinal cord, meninges, and cerebrospinal fluid through a vertebral defect, making it the most severe form of spina bifida.
Which priority nursing goal should be included in the care plan for an infant with myelomeningocele after surgical repair?
A. Promoting normal motor development
B. Preventing infection at the surgical site
C. Encouraging early ambulation
D. Managing electrolyte imbalances
B. Preventing infection at the surgical site
Rationale: Post-operative infection prevention is a top priority due to the infant’s increased risk for complications such as meningitis or wound infection after myelomeningocele repair.
A 3-week-old infant is brought to the clinic with projectile vomiting after feedings and poor weight gain. On assessment, the nurse notes visible peristaltic waves in the upper abdomen and a palpable olive-shaped mass in the right upper quadrant. Based on these findings, which diagnosis does the nurse anticipate?
A. Intussusception
B. Gastroesophageal reflux disease (GERD)
C. Pyloric stenosis
D. Hirschsprung disease
C. Pyloric stenosis
Rationale: Pyloric stenosis is characterized by projectile vomiting, visible peristalsis, and a palpable olive-shaped mass in the right upper quadrant, caused by the hypertrophy of the pyloric muscle, obstructing gastric emptying.
The nurse is assessing an infant with suspected pyloric stenosis. Which findings would the nurse expect to document?
Select all that apply:
- Projectile vomiting after feedings
- Metabolic alkalosis
- Dehydration signs, such as sunken fontanelles
- Ribbon-like stools
- Olive-shaped mass in the abdomen
- Projectile vomiting after feedings
- Metabolic alkalosis
- Dehydration signs, such as sunken fontanelles
- Olive-shaped mass in the abdomen
Rationale:
* Option 1: Projectile vomiting is a hallmark symptom of pyloric stenosis due to obstruction at the pylorus.
* Option 2: Excessive vomiting leads to loss of stomach acid, resulting in metabolic alkalosis.
* Option 3: Dehydration occurs due to fluid loss from vomiting. Signs include sunken fontanelles and dry mucous membranes.
* Option 4: Ribbon-like stools are associated with Hirschsprung disease, not pyloric stenosis.
* Option 5: An olive-shaped mass in the abdomen is a classic finding, representing the hypertrophied pylorus.
A 5-week-old infant with pyloric stenosis is admitted with a history of excessive vomiting. The nurse understands that the infant is at risk for which of the following complications?
A. Hypokalemia and metabolic acidosis
B. Hyperkalemia and respiratory acidosis
C. Hypokalemia and metabolic alkalosis
D. Hypernatremia and metabolic alkalosis
C. Hypokalemia and metabolic alkalosis
Rationale: Excessive vomiting in pyloric stenosis results in the loss of gastric acid (hydrogen and chloride ions), leading to metabolic alkalosis. Additionally, potassium is lost in vomiting and through compensatory renal mechanisms, causing hypokalemia.
The nurse is assessing a 7-year-old child with a head injury. Which finding indicates an early sign of increased intracranial pressure (ICP)?
A. Bradycardia
B. Vomiting without nausea
C. Fixed and dilated pupils
D. Cushing’s triad
B. Vomiting without nausea
Rationale: Vomiting without nausea is an early sign of increased ICP, often caused by pressure on the medulla. Other early signs include headache, irritability, and slight changes in behavior or level of consciousness. Bradycardia, fixed and dilated pupils, and Cushing’s triad are late signs.
The nurse is assessing a child with suspected increased intracranial pressure. Which findings would indicate late signs of increased ICP?
Select all that apply:
- Decerebrate posturing
- Fixed and dilated pupils
- Decreased level of consciousness
- Seizures
- Bradycardia
- Decerebrate posturing
- Fixed and dilated pupils
- Bradycardia
Rationale:
* Option 1: Decerebrate posturing occurs with severe brain injury and is a late sign of increased ICP.
* Option 2: Fixed and dilated pupils indicate brainstem compression and are a late, ominous sign.
* Option 3: Decreased level of consciousness can occur early or late, depending on severity.
* Option 4: Seizures can be an early or late sign but are not definitive of late ICP.
* Option 5: Bradycardia, part of Cushing’s triad, is a late sign indicating impending herniation.
A 10-year-old child is admitted after a fall from a tree. The nurse notes the following: lethargy, irritability, intermittent headache, and vomiting. Four hours later, the child becomes bradycardic, with irregular respirations and widening pulse pressure.
What priority intervention should the nurse take?
A. Administer prescribed antipyretics
B. Elevate the head of the bed to 15 degrees
C. Notify the healthcare provider immediately
D. Perform a neurological assessment every hour
C. Notify the healthcare provider immediately
Rationale: The progression to bradycardia, irregular respirations, and widening pulse pressure indicates Cushing’s triad, a late and life-threatening sign of increased ICP. Immediate action is necessary to prevent further deterioration or herniation.
The nurse is performing a neurological assessment on a child with suspected increased ICP. Which assessment finding would the nurse expect in the early stages?
A. Irritability and restlessness
B. Positive Babinski reflex
C. Posturing of the extremities
D. Coma
A. Irritability and restlessness
Rationale: Irritability and restlessness are early signs of increased ICP due to pressure on brain structures. These symptoms may precede more severe changes like posturing or coma, which occur in later stages.
The nurse is teaching the parents of a child with dehydration about rehydration methods. Which instructions should the nurse include?
Select all that apply:
A. Use oral rehydration solutions for mild dehydration.
B. Avoid giving juices or sports drinks for rehydration.
C. Administer small, frequent amounts of fluid if the child is vomiting.
D. Continue breastfeeding or formula feeding as tolerated.
E. Restrict fluids until the child’s symptoms subside.
A. Use oral rehydration solutions for mild dehydration.
B. Avoid giving juices or sports drinks for rehydration.
C. Administer small, frequent amounts of fluid if the child is vomiting.
D. Continue breastfeeding or formula feeding as tolerated.
Rationale:
* A. Oral rehydration solutions are recommended for mild dehydration as they replace lost fluids and electrolytes.
* B. Juices and sports drinks are avoided due to their high sugar content, which can worsen diarrhea.
* C. Small, frequent sips help prevent vomiting while still promoting hydration.
* D. Breastfeeding or formula feeding should continue as they provide fluids and nutrients.
* E. Fluid restriction is contraindicated, as adequate hydration is critical for recovery.
A 3-year-old child is admitted with moderate dehydration. The healthcare provider prescribes oral rehydration therapy (ORT). Which of the following fluids should the nurse offer to the child?
A. Plain water
B. Commercial electrolyte solution
C. Carbonated soda
D. Whole milk
B. Commercial electrolyte solution
Rationale: Commercial electrolyte solutions, such as oral rehydration salts (ORS), are the treatment of choice for moderate dehydration. They provide the necessary balance of electrolytes and fluids to restore hydration. Plain water and whole milk lack adequate electrolytes, and carbonated soda is not recommended due to high sugar content and lack of electrolytes.
The nurse is caring for a child with severe dehydration secondary to gastroenteritis. Which intervention is the priority?
A. Begin oral rehydration therapy with small sips every 5 minutes
B. Provide the child with clear fluids and monitor for tolerance
C. Offer the child glucose-containing fluids to prevent hypoglycemia
D. Administer an IV bolus of isotonic fluid
D. Administer an IV bolus of isotonic fluid
Rationale: For severe dehydration, IV rehydration with isotonic fluids such as normal saline or lactated Ringer’s is the priority to rapidly restore circulating volume and prevent hypovolemic shock. Oral rehydration is suitable for mild to moderate dehydration but not severe cases.
A nurse is assessing a newborn male with a congenital abnormality of the urethral opening. The nurse notes the urethral opening is located on the underside of the penis. What is this condition called?
A. Hypospadias
B. Epispadias
C. Phimosis
D. Cryptorchidism
A. Hypospadias
Rationale: Hypospadias is a congenital condition where the urethral opening is located on the underside of the penis, rather than at the tip. Epispadias, in contrast, is the abnormal placement of the urethral opening on the top of the penis. Phimosis and cryptorchidism are unrelated conditions.
A nurse is educating the parents of a newborn diagnosed with epispadias. Which statement by the nurse is correct regarding this condition?
A. Epispadias occurs when the urethral opening is located on the underside of the penis.
B. Epispadias is always associated with other congenital anomalies, such as bladder exstrophy.
C. Epispadias is typically treated with antibiotics to prevent infection.
D. Epispadias can be corrected with circumcision.
B. Epispadias is always associated with other congenital anomalies, such as bladder exstrophy.
Epispadias involves the urethral opening being located on the top of the penis. It is often associated with bladder exstrophy and requires surgical correction. Antibiotics and circumcision are not standard treatments for epispadias.
The nurse is educating the parents of a male child diagnosed with hypospadias. Which of the following points should the nurse include in the teaching plan?
Select all that apply:
A. Hypospadias is typically identified at birth during a routine physical examination.
B. Surgical correction is often necessary and is usually performed between 6 and 12 months of age.
C. Hypospadias is caused by an infection during pregnancy.
D. Parents should avoid circumcision until after the surgical repair is performed.
E. Hypospadias can cause difficulty with urination and sexual function if left untreated.
A. Hypospadias is typically identified at birth during a routine physical examination.
B. Surgical correction is often necessary and is usually performed between 6 and 12 months of age.
D. Parents should avoid circumcision until after the surgical repair is performed.
E. Hypospadias can cause difficulty with urination and sexual function if left untreated.
Rationale:
* A. Hypospadias is typically diagnosed at birth.
* B. Surgical correction is often performed between 6 and 12 months of age to avoid complications.
* D. Circumcision is avoided until after surgical repair to preserve the foreskin for reconstructive purposes.
* E. If untreated, hypospadias can lead to difficulties with urination and sexual function.
* C. Hypospadias is not caused by an infection but by abnormal development during fetal growth.
A healthcare provider is explaining the potential complications of untreated hypospadias to the parents of a male child. Which of the following complications should the nurse emphasize?
A. Urinary tract infections (UTIs)
B. Renal failure
C. Testicular torsion
D. Hydrocele formation
A. Urinary tract infections (UTIs)
Rationale: Untreated hypospadias can cause urinary flow abnormalities, leading to an increased risk of urinary tract infections (UTIs). Renal failure, testicular torsion, and hydrocele formation are not direct complications of untreated hypospadias.
A 10-year-old child presents to the emergency department with abdominal pain, nausea, and fever. Upon physical examination, the nurse palpates the lower right abdomen and the child reports pain upon release of pressure. What is the most likely diagnosis?
A. Gallbladder disease
B. Acute appendicitis
C. Mesenteric adenitis
D. Irritable bowel syndrome
B. Acute appendicitis
Rationale: Pain in the lower right abdomen and tenderness with rebound pain (positive rebound tenderness) are classic signs of acute appendicitis. The location and characteristics of the pain are key indicators in diagnosing appendicitis.
The nurse is assessing a child with suspected appendicitis. The child reports pain starting around the umbilicus and then moving to the right lower quadrant. Which of the following is the most likely explanation for the pain pattern?
A. Early stage of acute appendicitis
B. Abdominal hernia
C. Acute gastroenteritis
D. Urinary tract infection
A. Early stage of acute appendicitis
Rationale: In the early stages of acute appendicitis, pain typically begins around the umbilicus and then localizes to the right lower quadrant as the appendix becomes inflamed and irritates the peritoneum.
The nurse is educating the parents of a child diagnosed with acute appendicitis. Which of the following complications should the nurse include in the discussion?
Select all that apply:
A. Perforation of the appendix leading to peritonitis
B. Formation of an abscess near the appendix
C. Chronic appendicitis if not treated promptly
D. Dehydration and electrolyte imbalances
E. Sepsis due to widespread infection
A. Perforation of the appendix leading to peritonitis
B. Formation of an abscess near the appendix
E. Sepsis due to widespread infection
Rationale:
- A. Perforation of the appendix is a severe complication that can lead to peritonitis and widespread infection.
- B. An abscess may form near the appendix as a result of inflammation and infection.
- E. Sepsis can occur if the infection from a perforated appendix spreads throughout the body.
- C. Chronic appendicitis is rare and typically does not occur if appendicitis is treated promptly.
- D. While dehydration may occur with vomiting and fever, it is not a primary complication of appendicitis itself.
A 15-year-old child presents to the emergency department with complaints of severe right lower quadrant pain, fever, and nausea. The nurse notices that the child is lying with their knees drawn up to their chest and is reluctant to move. What does this positioning suggest?
A. Pelvic inflammatory disease
B. Peritonitis secondary to ruptured appendix
C. Acute cholecystitis
D. Kidney stones
B. Peritonitis secondary to ruptured appendix
Rationale: The child’s positioning with knees drawn up and reluctance to move is indicative of peritonitis, often due to a ruptured appendix. This behavior is a common sign of severe abdominal pain and the body’s attempt to minimize irritation of the peritoneum.
