An infant is born with a sac protruding through the spine, containing cerebrospinal fluid, a portion of the meninges, and nerve roots. This condition is referred to as:
Myelomeningocele.
Meningocele.
Spina bifida occulta.
Anencephaly.
The Correct Answer is A
Choice A reason: Myelomeningocele is a neural tube defect where a sac containing cerebrospinal fluid, meninges, and nerve roots protrudes through a spinal defect. This causes neurological impairments, like paralysis, due to exposed neural tissue, matching the described condition and requiring urgent surgical intervention.
Choice B reason: Meningocele involves a sac with cerebrospinal fluid and meninges but no nerve roots, protruding through a spinal defect. It causes fewer neurological deficits than myelomeningocele, as neural tissue is not involved, making it incorrect for the described condition with nerve roots.
Choice C reason: Spina bifida occulta is a mild neural tube defect with no protruding sac, only a vertebral gap. It often causes no symptoms, unlike the described condition with a sac containing nerve roots, making this an incorrect diagnosis for the visible defect.
Choice D reason: Anencephaly is a severe neural tube defect with absent brain and skull parts, not a spinal sac with cerebrospinal fluid and nerve roots. It is incompatible with life and unrelated to the described spinal condition, making it an incorrect diagnosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Removing the traction boot during baths disrupts Buck extension traction, used to stabilize the femoral head in Legg-Calve-Perthes disease. Continuous traction maintains alignment, and removal risks joint displacement, delaying healing of the avascular necrosis affecting the femoral head.
Choice B reason: Repositioning every 2 hours prevents pressure ulcers and maintains circulation in a child in Buck traction for Legg-Calve-Perthes disease. Regular movement within traction limits reduces skin breakdown and promotes comfort, supporting healing of the femoral head by maintaining proper positioning.
Choice C reason: Antibiotic ointment is used for skeletal traction with pins, not Buck extension traction, which uses skin traction. Legg-Calve-Perthes disease treatment does not involve pins, making this action irrelevant, as there are no pin sites to manage for infection prevention.
Choice D reason: Reducing fluid intake is inappropriate, as adequate hydration supports circulation and healing in Legg-Calve-Perthes disease. Dehydration risks urinary and cardiovascular complications, hindering recovery from avascular necrosis, making this action counterproductive to the child’s overall health and treatment.
Correct Answer is C
Explanation
Choice A reason: A 109 ml/hour rate is excessive for a 13.5 kg child. Using the 4-2-1 rule (4 ml/kg/hour for the first 10 kg, 2 ml/kg/hour for the next 3.5 kg), the total is 47 ml/hour, not 109, which could cause fluid overload and cardiovascular strain.
Choice B reason: A 79 ml/hour rate overestimates maintenance fluids for a 13.5 kg child. The 4-2-1 rule yields 47 ml/hour (40 ml for 10 kg + 7 ml for 3.5 kg). Higher rates risk hypervolemia, potentially causing pulmonary edema or electrolyte imbalances in a child.
Choice C reason: For a 13.5 kg child, the 4-2-1 rule calculates maintenance fluids as 40 ml/hour (10 kg × 4 ml) + 7 ml/hour (3.5 kg × 2 ml) = 47 ml/hour, closest to 49 ml/hour. This rate maintains hydration without risking fluid overload, supporting renal and cardiovascular function.
Choice D reason: A 200 ml/hour rate is far too high for a 13.5 kg child, risking fluid overload, heart failure, or pulmonary edema. The correct maintenance rate, per the 4-2-1 rule, is approximately 47 ml/hour, making this choice dangerously excessive for pediatric fluid needs.
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