NUR353: Exam 3
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 - - 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?
Providing a rest period
2
Offering a reward for walking
3
Encouraging use of the spirometer
4
Administering the prescribed pain medication - - 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?
,NUR353: Exam 3
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 - - Characteristics of stools
-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 - - Instructions about
which high-sodium foods to avoid
-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
,NUR353: Exam 3
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. - - The infant is alert and
interactive
-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 - - suction and then oxygenate the
newborn
, NUR353: Exam 3
- 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 - - 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
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 - - 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?
Providing a rest period
2
Offering a reward for walking
3
Encouraging use of the spirometer
4
Administering the prescribed pain medication - - 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?
,NUR353: Exam 3
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 - - Characteristics of stools
-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 - - Instructions about
which high-sodium foods to avoid
-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
,NUR353: Exam 3
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. - - The infant is alert and
interactive
-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 - - suction and then oxygenate the
newborn
, NUR353: Exam 3
- 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 - - 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
