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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?

A.

Increasing fluid intake

B.

Inserting an indwelling catheter

C.

Maintaining prone positioning

D.

Preventing skin breakdown

Answer and Explanation

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.


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Correct Answer is A

Explanation

Rationale:

A. Keeping a dedicated thermometer in the toddler's room is an appropriate infection control measure to prevent cross-contamination with other patients.

B. RSV is primarily transmitted through droplet and contact, not airborne, so contact and droplet precautions are more appropriate than airborne precautions.

C. Nebulized racemic epinephrine is not typically used for RSV; it is more commonly used for croup. Treatment for RSV may include supportive care such as hydration and oxygen therapy.

D. While monitoring pulse oximetry is important, assessing it every 3 hours might be insufficient. Continuous monitoring may be more appropriate depending on the severity of the illness.

Correct Answer is A

Explanation

Rationale:

A. Developmental dysplasia of the hip (DDH) often presents with a limited range of motion in the affected hip, particularly in abduction.

B. Asymmetry of the gluteal skinfolds, not symmetry, is a typical finding in DDH. This asymmetry is due to the improper alignment of the hip joint.

C. A positive Barlow test, where the hip can be dislocated by adduction and posterior pressure, is indicative of DDH. A negative Barlow test would suggest the absence of DDH.

D. A pale and cool leg is not a common finding in DDH. This would be more indicative of a circulatory problem, not hip dysplasia.

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