When developing the plan of care for a child with cerebral palsy, which treatment would the nurse expect as least likely?
Skeletal traction.
Physical therapy.
Orthotics.
Occupational therapy.
The Correct Answer is A
Choice A rationale
Skeletal traction involves inserting a pin directly into the bone to apply a continuous pulling force, typically used for complex fractures or severe orthopedic deformities. This is generally not a primary or common treatment for cerebral palsy, where management focuses on function, muscle tone, movement, and joint stability using non-invasive or less invasive techniques.
Choice B rationale
Physical therapy is a fundamental and expected treatment for cerebral palsy (CP). It focuses on improving muscle strength, mobility, balance, gait, and coordination. Specific exercises and techniques are employed to maximize functional independence and minimize the progression of secondary musculoskeletal complications.
Choice C rationale
Orthotics, such as ankle-foot orthoses (AFOs) or braces, are commonly prescribed treatments in the plan of care for children with CP. They provide support, maintain proper body alignment, prevent or correct deformities, and enhance walking ability by assisting with muscle control and joint stability during movement.
Choice D rationale
Occupational therapy is an essential component of the CP treatment plan. It addresses fine motor skills, activities of daily living (ADLs) like dressing and feeding, and visual-motor integration. The goal is to maximize the child's independence in self-care, school, and play activities tailored to their specific deficits.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Positioning an infant with myelomeningocele in the supine position increases the risk of rupture or damage to the delicate sac, which contains neural tissue and cerebrospinal fluid. Proper positioning requires the infant to be prone or side-lying to prevent pressure on the defect, protecting the integrity of the meningeal sac before surgical repair. A pillow under the buttocks when supine does not eliminate the risk.
Choice B rationale
Covering the sac with a sterile, moist, nonadhesive dressing, such as saline-soaked gauze, is essential preoperative care. This prevents the sac from drying out and maintains the viability of the exposed neural tissues, while the nonadhesive nature minimizes tissue trauma upon removal. Saline is used as an isotonic solution that avoids osmotic shifts in the exposed tissue.
Choice C rationale
Wrapping the infant snugly in a blanket should be avoided because the pressure exerted by the blanket could easily rupture the fragile meningeal sac. The goal is to minimize all external pressure and contact with the defect site to prevent infection and further neurological damage prior to surgical closure.
Choice D rationale
Applying a diaper is contraindicated as the diaper edges would rub against the sac, causing irritation, potential breakdown, and increasing the risk of contamination from urine and feces. The sac must be kept clean and dry from contaminants; therefore, the infant is typically kept in an incubator without a diaper.
Correct Answer is D
Explanation
Choice A rationale
While voiding is expected, the normal range for the first void is typically within the first 24 to 48 hours of life. A newborn not voiding at exactly 24 hours warrants continued monitoring, but it is not an immediate emergency unless there are other signs of distress or an obvious obstruction.
Choice B rationale
Acrocyanosis is a normal, transient condition in the newborn characterized by a bluish discoloration of the hands and feet due to sluggish peripheral circulation. It is common for up to 24 hours after birth and does not require immediate intervention, only ongoing assessment to ensure central color is pink.
Choice C rationale
Most healthy newborns pass meconium, the first stool, within the first 24 hours of life, with almost all passing it by 48 hours. A lack of meconium passage at 24 hours requires investigation for potential intestinal issues, such as Hirschsprung's disease or meconium plug, but an elevated temperature signals more acute distress.
Choice D rationale
A temperature of 100.5 degrees F (38.1 degrees C) in a newborn, which is above the normal range (typically 97.7 to 99.5 degrees F or 36.5 to 37.5 degrees C), is a serious finding. Newborns are susceptible to rapid temperature changes, and hyperthermia can indicate sepsis, dehydration, or environmental issues requiring immediate assessment and intervention.
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