The nurse is educating parents of a child with a cleft palate.
What should the nurse instruct the parents to report immediately?
Facial paralysis.
Ear infections.
Increased intracranial pressure.
Drooling.
The Correct Answer is C
Choice A rationale
While facial paralysis is a serious condition, it is not typically associated with a cleft palate.
Choice B rationale
Ear infections are a common complication of a cleft palate, but they are not typically a sign of an immediate, serious problem.
Choice C rationale
Increased intracranial pressure is not a common complication of a cleft palate, but it is a serious condition that requires immediate medical attention.
Choice D rationale
Drooling is common in children with a cleft palate and is not typically a sign of a serious problem.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The statement “My baby will be placed under special lights if the test is elevated” indicates a need for further teaching. This statement is incorrect because phototherapy (special lights) is not used to treat phenylketonuria (PKU). PKU is a genetic disorder that results in the body’s inability to metabolize the amino acid phenylalanine. If left untreated, it can lead to intellectual disability and other serious health problems. The treatment for PKU involves a special diet that is low in phenylalanine. Therefore, the parent’s statement about using special lights for treatment indicates a misunderstanding about the nature of PKU and its treatment.
Choice B rationale
The statement “Sometimes the test is repeated in the doctor’s office at the 2-week check-up” is correct. PKU is usually diagnosed through a routine newborn screening test, and if the initial test results are positive or unclear, the test may be repeated.
Choice C rationale
The statement “My baby must take formula or breast milk before the test is done” is correct. For accurate results, the PKU test is done after the baby is 24 hours old and after the baby has had some protein in the diet.
Choice D rationale
The statement “This test checks for a genetic disorder that can be corrected by diet” is correct. PKU is a genetic disorder that can be managed with a special diet low in phenylalanine.
Correct Answer is B
Explanation
Choice A rationale
While assistance may be needed to comfort the toddler during the procedure, holding the toddler in a prone position is not the recommended position for a lumbar puncture.
Choice B rationale
Placing the toddler in a side-lying, knee-chest position is the correct position for a lumbar puncture. This position helps to open up the spaces between the vertebrae, making it easier to access the spinal canal.
Choice C rationale
Restraining the toddler for 1 hour after the procedure is not necessary and could cause distress to the toddler.
Choice D rationale
While swaddling the toddler in a warm blanket may provide comfort, it is not a necessary step in the administration of a lumbar puncture.
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