A nurse is collecting data from a child who has spina bifida occulta. Which of the following findings should the nurse expect?
Flaccid paralysis of lower extremities
Hip dislocation
Hydrocephalus
Dimple in sacral area
The Correct Answer is D
A. Flaccid paralysis of lower extremities:
Flaccid paralysis refers to a weakness or loss of muscle tone in the affected muscles, leading to decreased or absent movement. This finding is not typically associated with spina bifida occulta. Instead, it is more commonly seen in more severe forms of spina bifida, such as myelomeningocele, where there is significant involvement of the spinal cord and nerves.
B. Hip dislocation:
Hip dislocation can occur in individuals with myelomeningocele due to muscle weakness, abnormal muscle tone, and joint deformities associated with spinal cord defects. However, it is not typically associated with spina bifida occulta, which usually presents with less severe spinal cord involvement.
C. Hydrocephalus:
Hydrocephalus, characterized by the accumulation of cerebrospinal fluid within the brain, is a common complication of myelomeningocele due to disturbances in the flow and absorption of cerebrospinal fluid caused by the spinal defect. It is less commonly associated with spina bifida occulta, which typically involves a less severe spinal cord defect.
D. Dimple in sacral area:
This is the correct choice. A dimple, patch of hair, or birthmark in the lower back or sacral area is a common finding in spina bifida occulta. It occurs due to the incomplete closure of the spinal column during fetal development, leading to a small defect in the vertebrae. This is often a subtle manifestation of spina bifida occulta and may not cause significant symptoms or functional impairment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "At this age you should expect your child to be upset when you leave.": This statement provides normalcy to the parents' experience and reassures them that their child's reaction is typical for his age. It acknowledges the child's developmental stage and separation anxiety, helping to alleviate parental concerns.
B. "Your child needs to rest.": While rest is important for infants, this statement does not address the child's emotional needs or the parents' concerns about leaving their child. It may also minimize the significance of the child's distress.
C. "I will notify the provider of his behavior.": Notifying the healthcare provider may be appropriate if the child's distress continues or if there are concerns about the child's well-being, but this statement does not directly address the parents' concerns or provide guidance on how to manage the situation.
D. "Your child is responding to an overstimulating environment.": This statement suggests a possible cause for the child's distress but does not provide guidance or reassurance to the parents on how to address the situation or manage their child's reaction.
Correct Answer is A
Explanation
A. Give the child a stuffed animal: Providing a comforting item like a stuffed animal can help the child feel more secure and may offer some comfort during the parent's absence. This option is appropriate as it addresses the child's emotional needs.
B. Inform the child that her parent will be back in 2 hours: While it's helpful to provide reassurance to the child, a 2-year-old may not fully understand the concept of time, and telling them that their parent will return in 2 hours may not effectively alleviate their distress. This option may not be as immediately comforting as providing a tangible source of comfort.
C. Call the parent to return to the child's room: If possible, having the parent return to the child's room can provide the most direct comfort and reassurance to the child during a tantrum. However, it may not always be feasible for the parent to return immediately, especially if they are occupied or attending to other responsibilities.
D. Leave the child alone in the room for 5 minutes: Leaving the child alone during a tantrum can exacerbate feelings of distress and abandonment, potentially escalating the situation further. It's essential to provide support and reassurance to the child during moments of distress rather than leaving them alone.
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