An infant is admitted to the unit with a diagnosis of bladder exstrophy. What should the nurse prioritize when caring for a client with this condition?
Increasing fluid intake
Inserting an indwelling catheter
Maintaining prone positioning
Preventing skin breakdown
The Correct Answer is D
A. Increasing fluid intake is important for overall health but is not the primary concern in the initial management of bladder exstrophy.
B. Inserting a catheter may be necessary but is not the first priority in managing bladder exstrophy.
C. Prone positioning is generally not recommended for infants with bladder exstrophy; supine positioning may be preferable to prevent pressure on the exposed bladder.
D. Preventing skin breakdown is critical due to the constant exposure of the bladder and surrounding skin to urine, leading to a high risk of irritation and infection.
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Related Questions
Correct Answer is C
Explanation
A. Passing tar-like stools is normal for newborns within the first few days of life and does not indicate Hirschsprung disease.
B. Limited stooling and poor weight gain may suggest feeding issues but are not as indicative of Hirschsprung disease as the absence of stool.
C. The absence of stool (failure to pass meconium within 24-48 hours) is a classic sign of Hirschsprung disease, a condition where the absence of ganglion cells in the intestines leads to a blockage.
D. Passing hard, pellet-like stools may indicate constipation but is not specific to Hirschsprung disease, especially in a newborn.
Correct Answer is A
Explanation
A. Activities should be tailored to the child’s developmental level, as children with spastic cerebral palsy may have delays in reaching developmental milestones.
B. Corticosteroids are not typically used for cerebral palsy, as it is a non-progressive condition affecting motor function, not an inflammatory condition.
C. Cerebral palsy is non-progressive, meaning it does not worsen over time, though the muscle tightness (spasticity) may change as the child grows.
D. While prenatal screening can detect certain risk factors, it cannot predict the occurrence of cerebral palsy with certainty.
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