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
Rationale:
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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
Rationale:
A. Mild illnesses like nasopharyngitis (a common cold) do not typically contraindicate vaccination, so there is no need to delay immunization.
B. It is essential to evaluate for allergies to vaccine components, such as gelatin or neomycin, which could contraindicate the administration of the varicella vaccine.
C. The first dose of the varicella vaccine is recommended at 12-15 months of age, not at 4 years of age, so it is appropriate to administer it during this well-check.
D. The varicella vaccine is administered subcutaneously, not intramuscularly, so this is not the correct route for administration.
Correct Answer is D
Explanation
Rationale:
A. Bronchiolitis usually presents with wheezing and difficulty breathing, not drooling or inability to cough.
B. Asthma typically presents with wheezing, shortness of breath, and coughing, but not with drooling or an inability to cough.
C. Nasopharyngitis, or the common cold, usually causes symptoms like runny nose, cough, and sore throat, but not drooling or agitation.
D. Bacterial epiglottitis is a life-threatening condition characterized by drooling, agitation, inability to cough, and potential airway obstruction. The child often appears anxious and sits leaning forward in a "tripod" position.