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Author Question: A neonate is brought to the nursery three hours after birth for an assessment. The child was ... (Read 107 times)

jenna1

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A neonate is brought to the nursery three hours after birth for an assessment. The child was diagnosed with a unilateral club foot in utero. During the nursing assessment, a priority will be assessing:
 
  1. The size of the quadricep muscles in comparison to the calf muscles.
   2. Dorsiflexion and plantar flexion of the affected foot.
   3. Family history.
   4. Vital signs.

Question 2

A child is scheduled to have a tonsillectomy in two hours. The nurse's assessment should include:
 
  1. A question to see if the child snores or has difficulty breathing at times.
   2. Assessing for halitosis.
   3. The size of the tonsils.
   4. All of the above



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IAPPLET

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Answer to Question 1

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1. The difference in muscle mass at this age will not be a contributing factor to the child's status.
2. The amount of flexion can indicate the severity of the malformation.
3. Family history does not influence the care for this patient.
4. Vital signs will need to be taken, but the focus should be on the flexion capabilities of the foot.

Answer to Question 2

4
Feedback
1. Snoring and difficulty breathing are an indication of obstruction of the tonsils.
2. Halitosis is common in children with enlarged tonsils because of the bacterial content.
3. Tonsil size should be documented because removal of the entire tissue will need to occur during surgery.
4. Snoring and difficulty breathing are an indication of obstruction of the tonsils. Halitosis is common in children with enlarged tonsils because of the bacterial content. Tonsil size should be documented because removal of the entire tissue will need to occur during surgery.





 

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