The nurse is performing a newborn assessment on a 37-week-gestation newborn at 2 hours of life. The nurse notes a small tuft of hair on the lumbosacral area of the spine. Which neural tube defect will the nurse associate with this assessment finding?

Anencephaly

Spina bifida

Meningocele

Myelomeningocele

Answer and Explanation

The Correct Answer is B

Choice A reason: Anencephaly is a severe neural tube defect where a major portion of the brain, skull, and scalp is missing. It does not present with a tuft of hair on the lumbosacral area.

Choice B reason: Spina bifida, specifically spina bifida occulta, is associated with a small tuft of hair on the lumbosacral area. This condition involves a defect in the spinal column where the bones do not close completely, but the spinal cord and nerves are usually not affected.

Choice C reason: Meningocele is a type of spina bifida where the protective membranes (meninges) protrude through an opening in the spine, forming a sac filled with cerebrospinal fluid. While it involves a spinal defect, it does not typically present with a tuft of hair.

Choice D reason: Myelomeningocele is the most severe form of spina bifida where the spinal cord and nerves protrude through an opening in the spine. This condition often results in more significant neurological deficits and is not specifically associated with a tuft of hair on the lumbosacral area.

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Correct Answer is ["1"]

Explanation

The APGAR score assesses five criteria: Appearance (skin colour), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration (breathing effort). Each criterion is scored from 0 to 2, with a maximum total score of 10.

Appearance: The infant is pale, which scores 0.
Pulse: The heart rate is 99 beats per minute, which scores 1 (as it is below 100).
Grimace: No response to stimulus, which scores 0.
Activity: The infant is limp, which scores 0.
Respiration: No spontaneous respirations, which scores 0.

Summing these scores gives a total APGAR score of 1.

A. Walking unaided 15 steps. B. Holding a crayon. C. Copying a circle. D. Speaking 15 words.

Correct Answer is A

Explanation

Choice A reason: Walking unaided is a significant gross motor milestone that may be delayed in a child with chronic lung disease due to decreased physical stamina and energy levels. These children may tire easily, making it more challenging to develop the strength and coordination needed to walk independently. The need for supplemental oxygen can further limit the child's mobility and opportunities for practicing walking.

Choice B reason: Holding a crayon is a fine motor skill that may not be as significantly affected by chronic lung disease. While any serious health condition can impact overall development, fine motor skills like holding a crayon can be practiced in less physically demanding ways, even if the child has reduced stamina.

Choice C reason: Copying a circle is a developmental milestone typically expected later, around 3 years old. At 12 months, a child is not expected to perform this task, so it is not relevant in this context for identifying a delay at this age.

Choice D reason: Speaking 15 words is a language milestone that can be affected by various factors. However, chronic lung disease more directly impacts physical stamina and gross motor skills rather than speech development. While any health issue can influence overall development, speech and language milestones might not be as immediately impacted by chronic lung disease.

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The nurse is performing a newborn assessment on a 37-week-gestation newborn at 2 hours of life. The nurse notes a small tuft of hair on the lumbosacral area of the spine. Which neural tube defect will the nurse associate with this assessment finding?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for an infant delivered one minute ago. The infant has no spontaneous respirations, no response to stimulus, is limp, pale, and has a heart rate of 99 beats per minute. How will the nurse document this infant's APGAR Score? Enter number only (no units).

Correct Answer is ["1"]

Explanation

The nurse is caring for a 12-month-old diagnosed with chronic lung disease, receiving supplemental oxygen with a portable oxygen tank. What developmental milestone is likely to be delayed?

Correct Answer is A

Explanation

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