A nurse is assessing an 8-month-old infant for cerebral palsy. Which of the following findings is a manifestation of the condition?

Can always track an object with eyes

Needs support with pillow props for sitting

Uses a pincer grasp to pick up a toy

Smiles when a parent appears

Answer and Explanation

The Correct Answer is B

A. Can always track an object with eyes:

The ability to track an object with the eyes typically develops in infants around 2 to 3 months of age. This developmental milestone is not specific to cerebral palsy and is generally expected in healthy infants.

B. Needs support with pillow props for sitting

Explanation:

Cerebral palsy (CP) is a group of permanent movement disorders that appear in early childhood. It is caused by abnormal development or damage to the parts of the brain that control movement, balance, and posture. The symptoms of cerebral palsy can vary widely, but they are generally related to motor function and coordination.

The manifestation of needing support with pillow props for sitting is consistent with the motor impairments often seen in cerebral palsy. Children with cerebral palsy may have difficulties with muscle control and coordination, which can affect their ability to sit independently. The need for external support to maintain a sitting position is indicative of motor developmental delays or challenges associated with cerebral palsy.

C. Uses a pincer grasp to pick up a toy:

The pincer grasp, where a child uses the thumb and index finger to pick up small objects, usually develops around 9 to 12 months of age. This developmental milestone is not directly associated with cerebral palsy and is part of normal infant development.

D. Smiles when a parent appears:

Smiling in response to familiar faces, including parents, is a social and emotional developmental milestone that typically occurs around 2 to 3 months of age. While cerebral palsy can affect motor function, it does not directly impact an infant's ability to express emotions like smiling.

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Correct Answer is B

Explanation

A) Document intake and output:

Documenting intake and output is an important nursing task, but it is not the top priority in a suspected case of bacterial meningitis. Timely administration of antibiotics to treat the infection takes precedence over documentation of intake and output.

B) Administer antibiotics when available.

Explanation:

Bacterial meningitis is a serious and potentially life-threatening infection of the membranes covering the brain and spinal cord. Rapid administration of antibiotics is crucial to effectively treat the infection and prevent its spread. Delay in antibiotic administration can lead to worsening symptoms and complications. Therefore, getting the appropriate antibiotics to the child as soon as they are available is the nurse's priority.

C) Reduce environmental stimuli:

Reducing environmental stimuli can be helpful in managing symptoms and providing comfort to the child with meningitis, but it is not the priority action. The immediate concern in a suspected case of bacterial meningitis is to treat the infection.

D) Maintain seizure precaution:

While maintaining seizure precautions is important, especially if the child has a history of seizures, it is not the top priority in a suspected case of bacterial meningitis. Administering antibiotics to treat the infection and prevent its progression is the primary concern.

A. assess the bowel sounds B. Frequently ambulate child C. Weigh child weekly D. monitor and measure the abdominal girth

Correct Answer is D

Explanation

A. Assess the bowel sounds:

Bowel sounds are not directly related to the assessment of ascites. Bowel sounds are more relevant in assessing gastrointestinal function and peristalsis. While bowel changes could potentially be a sign of complications, monitoring abdominal girth is more specific to tracking ascites.

B. Frequently ambulate child:

While ambulation is important for overall health, it's not a direct assessment method for monitoring ascites. Ambulating a child might have benefits, but it won't provide specific information about the presence or progression of ascites.

C. Weigh child weekly:

Weekly weighing can provide some information about overall fluid balance, but it might not be as sensitive as measuring abdominal girth when it comes to detecting changes in ascites. Additionally, monitoring weight alone might not give insight into the distribution of fluid in the abdominal cavity.

D. Monitor and measure the abdominal girth.

Explanation: The presence of ascites (accumulation of fluid in the abdominal cavity) in a child with nephrotic syndrome could indicate worsening kidney function and fluid balance. Monitoring and measuring the abdominal girth is a reliable way to assess changes in the amount of fluid accumulation over time. An increase in abdominal girth could suggest a worsening condition.

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A nurse is assessing an 8-month-old infant for cerebral palsy. Which of the following findings is a manifestation of the condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?

Correct Answer is B

Explanation

An eight-year-old with nephrotic syndrome is pale, lethargic, and has ascites. To determine if the ascites is increasing, the nurse should (chose one best answer):

Correct Answer is D

Explanation

A nurse is providing teaching to a school-age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates an understanding of the teaching?

A 4-year-old with nephrotic syndrome is experiencing severe periorbital edema. The best measure the nurse could institute to help reduce the periorbital edema is:

A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client should indicate to the nurse a need for further teaching?

When measuring a 6-month-old baby in the hospital for seizures, the nurse obtains a head circumference that is up 1 cm from the last measurement one week ago. The nurse re-measures and gets the same number What is the best next step?

The mother of a 1-month-old infant tells the nurse she worries that her baby will get meningitis like the child's older brother had when he was an infant. The nurse should base her response on which of the following?

Why do we instruct care givers about preventing kidney injury in their baby or child under 2 years old?

Which of the following statements by a mother of a toddler diagnosed with nephrotic syndrome indicates that the mother understands the teaching about the disease?

A toddler diagnosed with nephrotic syndrome has a nursing diagnosis of excess fluid related to fluid accumulation (generalized edema). Which nursing intervention would be the priority to include in the nursing plan of care?