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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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View Related questions

Correct Answer is C

Explanation

Rationale:

A. A complete blood count is not specifically required before administering the rubella vaccine.

B. Lead screening is not related to rubella vaccination and is not required for this purpose.

C. The rubella vaccine is a live attenuated vaccine, and it is important to ensure that the patient is not pregnant because the vaccine could potentially harm the fetus. Therefore, a pregnancy test is a necessary precaution.

D. Tuberculosis screening is not related to the rubella vaccination and is not required for this purpose.

Correct Answer is A

Explanation

Rationale:


A. Bradycardia, constipation, and hypotonia are common symptoms associated with congenital hypothyroidism due to the reduced metabolism that results from decreased thyroid hormone levels.

B. Elevated serum T3 and T4 would not be expected in congenital hypothyroidism; these levels are typically low.

C. Tachycardia, diarrhea, and tremors are more indicative of hyperthyroidism, not hypothyroidism.

D. In congenital hypothyroidism, the thyroid-stimulating hormone (TSH) is typically elevated as the body attempts to stimulate the thyroid gland to produce more hormones.

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