A 9-month-old who is not sitting independently has been diagnosed ...

[ts19998]

A 9-month-old who is not sitting independently has been diagnosed with ataxic cerebral palsy (CP). Which of the following clinical manifestations would the nurse expect to see in the baby?
 
  1. Hemiplegia and hypertonia
   2. Hypotonia and muscle instability
   3. Tremors and exaggerated posturing
   4. Hypertonia and persistence primitive reflexes

Question 2

The nurse is analyzing data collected from the assessment of a child with a congenital heart defect that decreases pulmonary blood flow. Which of the following nursing diagnoses would be applicable for this client?
 
  1. Excess Fluid Volume
   2. Risk for Infection related to engorged pulmonary vasculature
   3. Interrupted Family Processes
   4. Decreased Cardiac Output

[nital]

Answer to Question 1

2. Hypotonia and muscle instability

Rationale:
Hypotonia in infancy and muscle instability are seen in ataxic CP. Hemiplegia and hypertonia are seen in spastic CP. Tremors and exaggerated posturing are seen in dyskinetic CP. Hypertonia and persistent primitive reflexes are seen in spastic CP.

Answer to Question 2

4. Decreased Cardiac Output

Rationale:
Nursing diagnoses seen in clients with congenital heart defects that decrease pulmonary blood flow include decreased cardiac output, risk for infection related to unfiltered bacteria in the blood, caregiver role strain, activity intolerance, and delayed growth and development. Excess fluid volume, risk for infection related to engorged pulmonary vasculature, and interrupted family processes are nursing diagnoses seen in the care of a client with a congenital heart defect that increases pulmonary blood flow.