The nurse reports to the healthcare provider signs of increased intracranial pressure in an infant with myelomeningocele who has which finding?

A fontanelle that bulges with crying

Increased respiratory rate

A high-pitched cry

Tachycardia

Answer and Explanation

The Correct Answer is A

A. A fontanelle that bulges with crying.

Myelomeningocele is a congenital neural tube defect that involves the spinal cord. It is associated with an increased risk of hydrocephalus, which can lead to increased intracranial pressure (ICP). The fontanelle (soft spot) on an infant's head can provide insight into ICP. When an infant with myelomeningocele has an increase in intracranial pressure, the fontanelle may bulge, especially when the infant cries. This is due to the buildup of cerebrospinal fluid within the skull.

B. Increased respiratory rate: While increased intracranial pressure can affect various body systems, an increased respiratory rate is not a specific sign of ICP associated with myelomeningocele.

C. A high-pitched cry: A high-pitched cry is not typically associated with increased intracranial pressure in the context of myelomeningocele. Signs of ICP in infants may include irritability, lethargy, vomiting, and changes in head circumference.

D. Tachycardia: Tachycardia can be a response to stress or discomfort in an infant, but it is not a specific indicator of increased intracranial pressure related to myelomeningocele.

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Correct Answer is B

Explanation

A. Prevent ear infections: While individuals with cleft palates are at increased risk of ear infections, the primary immediate goal is not ear infection prevention.

B. Establish feeding and sucking.

Clefts of the soft palate can make it challenging for the baby to create a proper seal for sucking and feeding. Ensuring that the baby can feed effectively is a crucial initial goal. This may involve special nipples, bottles, or breastfeeding techniques to help the baby get proper nutrition.

While eventually repairing the cleft palate is an important part of the overall care plan, the immediate goal is to ensure that the baby can feed and gain weight properly.

C. Repair the cleft palate: Surgical repair of the cleft palate is typically done when the child is older. The immediate concern for a newborn is feeding.

D. Help the mother bond with the baby: This is an important aspect of care but not the primary goal for the baby's health and well-being. Bonding can occur while addressing the baby's feeding needs.

A. Provide activities for the sing to do at home B. Avoid interruptions by coordinating using actions C. Anwer questions honestly and clearly D. Encourage the sibling to write in a journal

Correct Answer is C

Explanation

A. Provide activities for the sibling to do at home: While providing activities can be a good way to engage the sibling and offer a distraction, it may not address their need for understanding and emotional support. Answering questions and providing information about the condition is more directly beneficial in this context.

B. Avoid interruptions by coordinating using actions: This option is not clear and may not directly address the social support needs of the sibling. It's important to have open communication and address their concerns rather than coordinating actions to avoid interruptions.

C. Answer questions honestly and clearly.

In a situation where a 10-year-old sibling of a child with a complex chronic condition needs social support, providing honest and clear answers to their questions is essential. It's important to address their concerns and provide information in an age-appropriate manner. Children can feel anxious or confused when a sibling has a complex chronic condition, and providing honest and clear answers helps them understand the situation better and reduces their anxiety.

D. Encourage the sibling to write in a journal: While journaling can be a helpful coping strategy, it may not be the most immediate response to their social support needs. Answering questions and providing emotional support should come first.

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The nurse reports to the healthcare provider signs of increased intracranial pressure in an infant with myelomeningocele who has which finding?

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Naxlex Comprehensive Predictor Exams

Which is the primary goal for a newborn with a cleft of the soft palate?

Correct Answer is B

Explanation

To meet the social support needs of a 10 year-old sibling of a child with a complex chronic condition, the most appropriate nursing action is to

Correct Answer is C

Explanation

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