A nurse is assisting with the care of a child who has spina bifida.
Which of the following precautions should the nurse take while caring for this child?
Latex precautions.
Neutropenic precautions.
Seizure precautions.
Contact precautions.
The Correct Answer is A
Choice A rationale
Children with spina bifida often are allergic to latex, which can be found in medical gloves and things such as bandages, balloons, and pacifiers. Therefore, latex precautions should be taken while caring for a child with spina bifida.
Choice B rationale
Neutropenic precautions are typically used for patients with a low white blood cell count (neutropenia), which makes them more susceptible to infections. There is no specific association between spina bifida and neutropenia, so these precautions would not typically be necessary unless the child has a co-existing condition that causes neutropenia.
Choice C rationale
Seizure precautions are typically used for patients with a seizure disorder, such as epilepsy. While some individuals with spina bifida may also have a seizure disorder, it is not a common feature of the condition. Therefore, seizure precautions would not typically be necessary unless the child has a co-existing seizure disorder.
Choice D rationale
Contact precautions are typically used for patients who have an infection that can be spread by direct contact. There is no specific association between spina bifida and infectious diseases that would require contact precautions, so these precautions would not typically be necessary unless the child has a co-existing infectious disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A bulging fontanel is a common sign of increased intracranial pressure (ICP) in infants. The fontanels, or soft spots on an infant’s head, allow for brain growth. When there is increased pressure, as in conditions that cause increased ICP, it can cause the fontanels to bulge outwards.
Choice B rationale
Insomnia is not typically associated with increased ICP in infants. Changes in consciousness, such as irritability or lethargy, may be seen, but these are not the same as insomnia.
Choice C rationale
A low-pitched cry is not typically associated with increased ICP in infants. Changes in cry might occur, but they are not specific to increased ICP4.
Choice D rationale
A positive Babinski reflex is normal in infants up to about 12 months of age. It is not specifically associated with increased ICP4.
Correct Answer is D
Explanation
Choice A rationale
Understanding the cause of illness is a complex cognitive task that typically develops later in childhood. Preschool-aged children are still developing their understanding of cause and effect, and their thinking is often more concrete than abstract.
Choice B rationale
Describing manifestations of illness is also a complex task that requires a certain level of cognitive and language development. While preschool-aged children are developing their language skills rapidly, their ability to describe complex phenomena such as the manifestations of illness is still developing.
Choice C rationale
Awareness of body functioning is a concept that typically develops later in childhood. Preschool-aged children are still learning about their bodies and how they work. Their understanding of body functioning is often concrete and based on what they can see and feel.
Choice D rationale
Relating fears to magical thinking is a characteristic of preschool-aged children’s cognitive development. At this age, children’s thinking is often dominated by fantasy and magic. They may attribute events or experiences to magical causes, and their fears may be related to these magical beliefs.
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