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 C

Explanation

Option A is incorrect because Tanner staging is not solely based on developmental achievement according to age. It assesses physical development irrespective of age.

Option B is incorrect because it is not based on the color of pigmentation on the scrotum but rather on multiple physical characteristics.

Option C. Based on the development of pubic hair in girls.

The Tanner staging system, also known as sexual maturity rating or sexual maturity scale, is a system used to assess the sexual development of children and adolescents based on physical characteristics, primarily focusing on secondary sexual characteristics. It is used to assess the stage of puberty in both boys and girls. In the case of girls, it includes the development of pubic hair, breast development, and other changes like the growth of the areola.

Option D is incorrect because it doesn't solely focus on staged voice changes in males. The Tanner staging system includes a range of characteristics, including voice changes, genital development, and pubic hair growth, to assess sexual maturity in both males and females.

A. Increased ability of tissue to retain fluid B. Reduced blood pressure C. Increased diuresis and decreased protein loss in urine D. Decreased protein severs in serum

Correct Answer is C

Explanation

Options A (increased ability of tissue to retain fluid) and B (reduced blood pressure) are not typical signs of improvement in Nephrotic Syndrome. The primary focus is on reducing protein loss and alleviating edema.

Option C. Increased diuresis and decreased protein loss in urine.

Nephrotic Syndrome is characterized by increased urinary protein loss, resulting in hypoalbuminemia, edema, and other symptoms. Improvement in Nephrotic Syndrome is typically indicated by:

Increased diuresis: An increase in urine output suggests that the child is excreting excess fluid, which can help reduce edema (swelling).

Decreased protein loss in urine: A reduction in proteinuria (loss of protein in the urine) is a positive sign, as it indicates that the damaged kidney glomeruli are functioning more effectively in retaining protein.

Option D (decreased protein levels in serum) is also not a clear sign of improvement. While it may be related to reduced protein loss in urine, it does not directly reflect the overall improvement of the condition. Monitoring protein levels in the urine (proteinuria) is a more specific indicator of Nephrotic Syndrome management.

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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

The nurse is aware that the Tanner staging system for sexual maturity is:

Correct Answer is C

Explanation

What nursing assessment finding suggests that child with Nephrotic Syndrome is improving?

Correct Answer is C

Explanation

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