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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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. Appropriate dose of aspirin and rest B. Immobilization of the leg and a dose of ibuprofen C. Heating pad and administration of factor Vill concentrate D. Pressure on the site and administration of the required clotting factor

Correct Answer is D

Explanation

A. Appropriate dose of aspirin and rest: Aspirin is an antiplatelet medication that can worsen bleeding in individuals with hemophilia. It should be avoided. Rest alone is not sufficient in this situation.

B. Immobilization of the leg and a dose of ibuprofen: Ibuprofen is a non-steroidal anti-inflammatory drug (NSAID) that can increase the risk of bleeding. Immobilizing the leg may help prevent further injury, but it does not address the underlying bleeding issue or provide the necessary clotting factor.

C. Heating pad and administration of factor VIII concentrate: While the administration of factor VIII concentrate is appropriate, the use of a heating pad is not advisable, as it can potentially worsen bleeding by dilating blood vessels in the area.

D. Pressure on the site and administration of the required clotting factor.

Hemophilia is a bleeding disorder in which the blood doesn't clot properly. When a hemophilic child has a significant bruise or bleeding, it is crucial to administer the specific clotting factor that they are deficient in (Factor VIII or IX) to stop the bleeding. Applying pressure to the site can also help control bleeding.

In summary, option D is the priority because it directly addresses the bleeding issue in the child with hemophilia by applying pressure to the site and administering the necessary clotting factor. This is crucial in preventing further bleeding and complications.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is B

Explanation

Which intervention is a priority for a hemophilic child who has fallen and badly bruised his leg?

Correct Answer is D

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

A nurse in a summer day camp that has access to a local beach has cared for several children with Impetigo. What is the best nursing intervent to prevent complications?

The nurse observes that a client with sickle cell anemia and on a blood transfusion regimen has cardiac dysrhythmias due to iron overdose toxicity. Which medication is most beneficial to this client?

The nervous parent asks when the big "soft spot" (anterior fontanel) will be closed. The nurse's most informative response would be

Which action should the nurse take when providing postoperative nursing care to a child after insertion of ventriculoperitone (VP) shunt?

The nurse is taking care for the child that has been diagnosed with acute renal failure. Which findings should the nurse expect to see in this child?

A 3-year-old child with mild iron deficiency anemia is seen by a nurse in the clinic. In addition to weakness and fatigue, what should the nurse expect the child to exhibit?