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.
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Correct Answer is B
Explanation
Rationale:
A. The Moro reflex, where the infant cries and extends both arms and legs in response to a loud noise, typically disappears by 4-6 months of age and would not be expected at 8 months.
B. The Babinski reflex, where the toes fan upward and out when the outer edge of the sole is stroked, is normal in infants and usually disappears by 12-24 months of age.
C. The tonic neck reflex (fencing reflex) typically disappears around 4-6 months of age, so it would not be expected in an 8-month-old.
D. The rooting reflex, where the infant turns their head toward the side of stimulation when the cheek is stroked, typically disappears by 3-4 months of age.
Correct Answer is A
Explanation
Rationale:
A. Circumcision is often delayed in newborns with hypospadias because the foreskin may be needed for the surgical repair of the urethra.
B. While surgery is necessary, it is not typically an emergency; it is planned and performed later in infancy.
C. In hypospadias, the urethral opening is located on the underside (ventral side) of the penis, not the top.
D. Undescended testicles (cryptorchidism) are a separate condition from hypospadias.