A nurse is teaching the parents of an infant with cerebral palsy on how to provide optimal care. What should the nurse include in the teaching?

Continue to offer a special formula to limit gagging

Maintain immobility of the limbs with splints

Preserve muscle tone to prevent joint contractures

Focus on cognitive rather than motor skills.

Answer and Explanation

The Correct Answer is C

A. Continuing to offer a special formula to limit gagging is not a standard approach in the care of infants with cerebral palsy. The choice of formula should be based on the child's nutritional needs, and any feeding difficulties should be addressed by a healthcare professional.

B. Maintaining immobility of the limbs with splints is not recommended. Encouraging movement and mobility is important for the development and well-being of children with cerebral palsy.

C. Preserve muscle tone to prevent joint contractures.

Cerebral palsy is a condition that can lead to problems with muscle tone and movement. Preserving muscle tone is important to prevent joint contractures, which can limit mobility and cause pain. Physical therapy and exercises can help maintain muscle tone and joint flexibility in children with cerebral palsy.

D. Focusing on cognitive rather than motor skills is not appropriate. Motor skills are a crucial aspect of development for children with cerebral palsy. The approach should encompass both cognitive and motor skill development as appropriate for the child's age and abilities.

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Correct Answer is B

Explanation

A. Positive Western blot test: A positive Western blot test confirms HIV infection but doesn't provide information about the current immune status or progression of the disease.

B. CD4-T-cell count 180 cells/mm³.

The CD4-T-cell count is a crucial indicator of a person's immune system function, and it's a primary marker used to monitor the progression of HIV infection. A CD4 count of 180 cells/mm³ is significantly below the normal range (which is typically higher), indicating immunosuppression and an increased risk of opportunistic infections. Maintaining and improving immune function is a top priority in the care of clients with HIV.

C. Platelets 150,000/mm³: Platelet counts are important, but they are not the primary indicator for assessing the progression of HIV.

D. WBC 5.000/mm³: The white blood cell count (WBC) is important for assessing overall immune function, but it doesn't provide the same specific information about the immune system status as the CD4-T-cell count.

A. Place the infant in reverse Trendelenburg position B. Place the infant in the knee to chest position C. Take the infant's blood pressure in all extremities D. Notify the Physician

Correct Answer is C

Explanation

Option A (Place the infant in reverse Trendelenburg position) and option B (Place the infant in the knee to chest position) are not the immediate actions to address this situation. While these positions might be used in specific situations, assessing blood pressure is more appropriate in this context to evaluate for potential vascular issues.

Option C. Take the infant's blood pressure in all extremities.

In an infant with weaker femoral pulses compared to the brachial and radial pulses, there might be a concern about coarctation of the aorta (a narrowing of the aorta), which can affect blood flow to the lower extremities. To confirm this and assess for potential issues, taking blood pressure measurements in all four extremities is crucial. This comparison can help identify pressure differentials between the upper and lower extremities, which is a hallmark sign of coarctation of the aorta.

Option D (Notify the Physician) is generally a good step, but taking the blood pressure in all extremities should be done first to provide comprehensive information for the physician when discussing the infant's condition.

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A nurse is teaching the parents of an infant with cerebral palsy on how to provide optimal care. What should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?

Correct Answer is B

Explanation

The nurse is performing an admission assessment on the neonate and finds femoral pulses to be weaker than the brachial and radial pulses. The next nursing action should be

Correct Answer is C

Explanation

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