What is the priority nursing intervention to perform on an infant immediately following repair of a myelomeningocele?

Assess motor function in lower extremities

Maintain skin integrity

Monitor intake and output

Monitor head circumference

Answer and Explanation

The Correct Answer is D

A. Assess motor function in lower extremities: While important for overall neurological assessment, immediate post-repair monitoring of motor function is secondary to monitoring for signs of hydrocephalus (head circumference).
B. Maintain skin integrity: Essential for preventing infection but does not address the immediate post-surgical complication of hydrocephalus.
C. Monitor intake and output: Important for general post-operative care but does not address the immediate concern of monitoring for hydrocephalus.
D. Monitor head circumference: Following repair of a myelomeningocele, infants are at risk for developing hydrocephalus due to abnormal cerebrospinal fluid dynamics. Monitoring head circumference helps detect early signs of increased intracranial pressure, a common complication post-surgery.

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Correct Answer is ["B","C","E"]

Explanation

A. Chronic fatigue. While chronic fatigue can occur in muscular dystrophy due to muscle weakness, it is not a direct side effect of corticosteroids.
B. Weight gain: Corticosteroids commonly cause weight gain due to increased appetite and fluid retention.
C. Mood changes: Mood swings and changes in behaviour are well-documented side effects of corticosteroid use.
D. Weight loss. Corticosteroids typically cause weight gain rather than weight loss.
E. Osteoporosis: Long-term use of corticosteroids can lead to decreased bone density and osteoporosis, making bone fractures more likely.

A. Hypertonia B. Large ears C. Transverse palmar creases D. Protruding tongue E. Low birth weight

Correct Answer is ["C","D"]

Explanation

Answer: C, D

A. Hypertonia
Hypertonia, or increased muscle tone, is not a common characteristic of Trisomy 21. In fact, many infants with Down's Syndrome typically exhibit hypotonia, or decreased muscle tone, which can affect their overall strength and development.

B. Large ears
While individuals with Down's Syndrome may have unique ear shapes, "large ears" are not specifically characteristic of Trisomy 21. Instead, the ears may appear small or have a different shape compared to those of typically developing children.

C. Transverse palmar creases
Transverse palmar creases, also known as simian lines, are commonly seen in individuals with Down's Syndrome. This feature is a characteristic finding that can help in identifying the condition during physical assessment.

D. Protruding tongue
A protruding tongue is a common feature in individuals with Down's Syndrome. This occurs due to hypotonia of the oral muscles, which can lead to difficulties in tongue control and positioning.

E. Low birth weight
Low birth weight is not a defining characteristic of Trisomy 21. In fact, newborns with Down's Syndrome can have varying birth weights; they are often average weight or slightly above average, although some may be below average due to other factors related to maternal health or gestational issues.

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What is the priority nursing intervention to perform on an infant immediately following repair of a myelomeningocele?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When caring for a 13-year-old with muscular dystrophy receiving corticosteroids to slow disease progression, which of the following medication side effects would you assess for? (Select All that Apply.)

Correct Answer is ["B","C","E"]

Explanation

A nurse is assessing a newborn who has Trisomy 21 (Down's Syndrome). Which of the following are common characteristics? (Select All that Apply.)

Correct Answer is ["C","D"]

Explanation

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