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

Answer and Explanation

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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Correct Answer is C

Explanation

A. A capillary refill greater than 3 seconds suggests ongoing dehydration and poor perfusion, indicating that oral rehydration has not been fully effective.

B. A respiratory rate of 24/min is within normal limits for a 4-year-old but is not a direct indicator of hydration status.

C. A urine specific gravity of 1.015 is within the normal range, indicating adequate hydration and that oral rehydration therapy has been effective.

D. A heart rate of 130 bpm, while potentially normal for a 4-year-old, does not specifically indicate the effectiveness of rehydration therapy.

A. Partial thromboplastin time B. Hemoglobin level C. Platelet count D. Hematocrit level

Correct Answer is A

Explanation

A. Hemophilia is a bleeding disorder that affects the clotting process, and the partial thromboplastin time (PTT) is typically prolonged in individuals with hemophilia, indicating a deficiency in clotting factors.

B. Hemoglobin levels may remain normal unless the client experiences significant bleeding episodes.

C. Platelet count is usually normal in hemophilia, as the disorder affects clotting factors rather than platelet production.

D. Hematocrit levels may also remain normal unless there is significant bleeding, which would lower hematocrit due to blood loss.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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