The nurse is caring for 3-day-old girl with Down syndrome whose ...

[Wadzanai]

The nurse is caring for 3-day-old girl with Down syndrome whose mother had no prenatal care. Which of the following will be the priority nursing diagnosis?
 
  A) Imbalanced nutrition, less than body requirements related to the effects of hypotonia
  B) Deficient knowledge related to the presence of a genetic disorder
  C) Delayed growth and development related to a cognitive impairment
  D) Impaired physical mobility related to poor muscle tone

Question 2

The nurse is developing a plan of care for a child who is receiving cyclophosphamide. Which of the following would the nurse expect to include?
 
  A) Withholding food and fluids from the child during the infusion
  B) Encouraging frequent voiding during and after the infusion
  C) Monitoring for signs of anaphylaxis during infusion
  D) Assessing the child for complaints of bone pain

[steff9894]

Answer to Question 1

A
Feedback:
Children with Down syndrome may have difficulty sucking and feeding due to lack of muscle tone and the structure of their mouths and tongues. This can lead to poor nutritional intake and makes this the priority diagnosis. This also uses the strategy that physiologic needs have priority using Maslow's hierarchy of needs. Deficient knowledge due to lack of information about the disorder is a close second in priority, as the mother did not know of her daughter's condition before birth and has much to learn now. This child is at risk for a number of complications such as infection, heart disease, and leukemia and will require frequent assessment. Most children with Down syndrome experience some degree of intellectual disability, but early intervention will allow the child maximum development within the limits of the disease. Mobility is delayed but should not be a problem at this time.

Answer to Question 2

B
Feedback:
Cyclophosphamide may cause hemorrhagic cystitis. Therefore, the nurse needs to provide adequate hydration and have the child void frequently during and after the infusion to decrease the risk of hemorrhagic cystitis. Fluids need to be encouraged, not withheld. Monitoring for anaphylaxis would be appropriate when asparaginase or etoposide is given. Bone pain is associated with the administration of filgrastim or sargramostim.

[Wadzanai]

Excellent

[Sarahjh]

TYSM