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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Demonstrating independent dressing is usually not expected at 18 months. Toddlers are still developing fine motor skills and may need assistance with dressing.
B. Using a vocabulary of 300 words is advanced for an 18-month-old. At this age, most children have a more limited vocabulary, typically around 50 words or so.
C. Jump with both feet.
At 18 months of age, children are usually developing their motor skills, including gross motor skills like walking, running, and jumping. Jumping with both feet is an age-appropriate milestone for a toddler of this age.
D. Walking upstairs with one hand held is typically not expected at 18 months. This is a skill that develops later as toddlers gain more confidence in their mobility and coordination.
Correct Answer is A
Explanation
Hemophilia is a genetic bleeding disorder in which the blood does not clot properly. It primarily affects the coagulation factors responsible for clot formation. In individuals with hemophilia, bleeding tends to occur most commonly in the joints, particularly in the large weight-bearing joints like the knees, elbows, and ankles. This is known as hemarthrosis and can lead to significant pain and joint damage.
While bleeding in other areas of the body can occur in hemophilia, such as the muscles or soft tissues, joint bleeding is one of the hallmark features of the condition.
The other options, B (intestines), C (brain), and D (pericardium), are less commonly associated with bleeding in hemophilia. Although bleeding can occur in various locations, joint bleeding is the most characteristic and commonly seen manifestation in individuals with hemophilia.
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