NCLEX Preparation Course - Critical Thinking Exercises VI QUESTIONS (61-70) -->
61) B
- Myelomeningocele is a type of neural tube defect characterized by herniation of spinal cord (spinal nerves) and the meninges at an opening in the spinal column forming a sac on the baby's back that is prone to infection and damage. Sometimes skin covers the sac. In other cases there is no skin above it so that the meninges and nerves are exposed to air.
The common complications associated with myelomeningocele are paralysis, hydrocephalus, meningitis, bladder and bowel incontinence, learning disabilities, and joint deformities (clubfoot and hip dysplasia).
Meningitis is an infection and inflammation of the meninges and cerebrospinal fluid surrounding the brain and spinal cord.
Signs and Symptoms include:
1. Under 2 year old: High pitched cry, fever, vomiting, resistance to being held, bulging fontanel, poor feeding, opisthotonus.
2. Older children:
- kernig's sign (pain on hamstring muscles on extension of legs with hips flexed)
- bruzinskin sign (flexion at hip and knee with flexion of neck)
- tripod posturing
- nucchal rigidity
- vomiting
- high fever
- headache
- skin rash especially near the armpits or on the hands or feet
- rapid progression of small hemorrhages under the skin
- photophobia
- seizures
- progressive lethargy and drowsiness
- sunset eyes is seen in hydrocephalus
62) C
- high pitch cry is a sign of increased intracranial pressure. The neck and the back of the infant with meningitis is usually rigid not the extremities.
63) C
- Meningocele and myelomeningocele requires surgery to put the meninges and the spinal cord back in place and close the opening in the vertebrae. The opening is closed by covering it with skin and muscle. Any sensory and motor deficit the child has will not be corrected by surgery. Therefore the child will need a urologist to help with problems in bowel and bladder incontinence. Routine bowel and bladder program needs to be initiated by age 2.
Physical therapy and rehabilitation is also important to help the child deal with motor loss, the child will need leg exercises that would prepare him for walking using crutches or braces when she get older.
64) D
- the child should be monitored for possible complication after surgery which are:
- hydrocephalus - observe for signs of increased ICP, palpate fontanel if it is bulging every 4 hours, observe for high pitched cry, measure head circumference every 8 to 12 hours
- meningitis - observe for fever, irritability, stiff-neck, poor suck, lethargy
- spinal cord dysfunction - incontinence, paralysis
65) D
- preoperative care for Nicole would be:
- prevention of infection
- administer prescribed antibiotics
- do not apply diaper to protect the sac from irritation and contamination
- observe for signs of infection increased ICP, meningitis (fever, irritability, nunchal rigidity)
- cover the exposed sac with sterile moistened saline dressing
- place newborn in prone position with legs abducted to prevent dislocation and the head turned on the side
- protect sac with sponge doughnut when holding infant
- observe for leakage
66) A
- this client is now stable. So, he can safely be discharged67) C
- apply dermatologic medications thinly (1/8" to 1/16") to prevent systemic absorption of the medications. This in turn, prevents toxicity.68) C
- Pyloric Stenosis is a genetic disorder common among first born white male infants characterized by narrowing of the pylorus (the sphincter between the stomach and small intestines) due to edema (from hypertrophy and hyperplasia of cells) preventing the passage of food from the stomach to the intestines. This disorder becomes evident around 4 weeks among formula fed babies and 6 weeks in breastfed babies.
Diagnostic Test: Observe for peristalsis while drinking
- before drinking - palpate RUQ and locate pyloric mass - round, firm, size of an olive
- while drinking - observe gastric peristalsis wave from left to right side of abdomen
- after drinking - child experiences projectile vomiting
1. An olive-sized mass in the right upper quadrant on palpation which is the hypertrophied pylorus
2. Vomiting caused by narrowing of pyloric sphincter prevents passage of food from stomach to intestines
- vomiting after feeding which smell sour due to hydrochloric acid
- vomitus does not contain bile because it has not yet reached intestines
- the child is hungry and will feed after vomiting because the child does not feel nauseated
- Fredet-Ramstedt Operation - it is the surgical incision of the pyloric to enlarge the opening from the esophagus to the stomach.
Pre-op:
- IVF to correct fluid and electrolyte imbalance-isotonic saline or 5% glucose
- NPO, provide pacifier
- IV calcium for tetany
- NGT to drain GIT secretions and prevent abdominal distention - apply adequate restraint on the child to prevent him from pulling the tubing
- if child feels nauseated while NGT is in place, suspect obstruction of NGT
- down's regimen of feeding: - 1 tsp glugose water by bottle feeding every hour for four hours to see if the child can retain clear fluids. If child did not vomit, give 2 tsp every hour for four hours. Then half strength formula every four hours. By 24 to 48 hours, the child is receiving full or regular strength formula
- place on infant seat of in upright position after feeding to prevent vomiting
- the child must take formula to prevent bowel adhesion. Do not keep on NPO for a long time
- the child must not take more than required formula to prevent distention and damage of suture
- expect to be discharge at 48 hours after surgery
- surgical site in the abdomen may be covered by colloidion - fold diaper below it. If soaked with urine or feces, wash with soap and water and keep dry
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