INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK
Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 125
Chapter 14: The Newborn with a Perinatal Injury or Congenital
Malformation
MULTIPLE CHOICE
1. What occurrence results from obstruction within the ventricles of the brain or inadequate reabsorption of
cerebrospinal fluid?
a. Meningitis
b. Meningocele
c. Spina bifida occulta
d. Hydrocephalus
ANS: D
Hydrocephalus is characterized by an increase in cerebrospinal fluid in the ventricles of the brain.
DIF: Cognitive Level: Knowledge REF: Page 329
TOP: Hydrocephalus KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. The nurse is caring for an infant with hydrocephalus. What nursing action is most important for this nurse to
implement?
a. Align the limbs.
b. Support the head.
c. Keep the head lower than the hip.
d. Check intake and output.
ANS: B
The child with hydrocephalus has a heavy head on a small body with poor muscle tone; the head must be
supported when feeding and moving the childNURSINGTB.COM
to prevent injury to the neck.
DIF: Cognitive Level: Application REF: Page 331
TOP: Hydrocephalus KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
3. The nurse observes that the infants anterior fontanelle is bulging after placement of a ventriculoperitoneal
shunt. How should the nurse position this infant?
a. Prone, with the head of the bed elevated
b. Supine, with the head flat
c. Side-lying on the operative side
d. In a semi-Fowlers position
ANS: D
If the fontanelles are bulging, the child will be positioned in a semi-Fowlers position to promote drainage from
the ventricles through the shunt.
DIF: Cognitive Level: Application REF: Page 331
OBJ: 4 TOP: Hydrocephalus
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
4. What nursing action will the nurse implement after feeding an infant with hydrocephalus?
a. Position the infant sitting upright in an infant seat.
b. Place the infant over the shoulder to burp.
c. Leave the infant in a side-lying position.
d. Stimulate the infant by rubbing its feet.
ANS: C
Because children with hydrocephalus are prone to vomiting, the child is fed and then positioned in the side-
NURSINGTB.COM
, INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK
Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 126
lying position in a quiet atmosphere to reduce the incidence of vomiting.
DIF: Cognitive Level: Application REF: Page 331
TOP: Feeding a Hydrocephalic Child KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
5. A newborn was just admitted to the neonatal intensive care unit with a meningomyelocele. What is the
priority preoperative nursing care of this newborn?
a. Keep the sac dry.
b. Diaper snugly.
c. Position prone in an incubator.
d. Move from side to side every hour.
ANS: C
The infant is placed prone in a humidified incubator, and the sac is covered with dressings of sterile saline. The
infants hips are kept lower than the lesion, and the infant is usually not in diapers.
DIF: Cognitive Level: Analysis REF: Page 333
TOP: Myelodysplasia and Spina Bifida KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
6. The nurse is caring for a child who has had a ventriculoperitoneal shunt (VP) for hydrocephalus and
observes an increasing abdominal girth. What is the most appropriate response?
a. Elevate the childs head.
b. Check bowel sounds.
c. Record retention of feeding.
d. Notify the charge nurse of possible malabsorption.
ANS: D
An increasing abdominal girth in a child with NURSINGTB.COM
a VP shunt may be indicative of malabsorption of the
cerebrospinal fluid (CSF) that is being shunted to the peritoneum.
DIF: Cognitive Level: Application REF: Page 331
OBJ: 6 TOP: VP Shunt KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
7. The nurse is providing education to parents of a child with cleft palate. What will the nurse instruct the
parents to report immediately?
a. Facial paralysis
b. Ear infections
c. Increasing intracranial pressure (ICP)
d. Drooling
ANS: B
Children with cleft palate are at risk of ear infections and dental disorders. Parents should be instructed to take
the child to the health care provider at the first sign of earache.
DIF: Cognitive Level: Application REF: Page 336
TOP: Complication of Cleft Palate KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
8. Postoperative nursing care of the infant following surgical repair of a cleft lip would include:
a. Feeding the infant with a spoon to avoid sucking
b. Positioning the infant on the abdomen to facilitate drainage
c. Applying elbow restraints to protect the surgical area
d. Providing minimal stimulation to prevent injury to the incision
ANS: C
Elbow restraints are used postoperatively to prevent the infant from damaging the operative area.
NURSINGTB.COM
Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 125
Chapter 14: The Newborn with a Perinatal Injury or Congenital
Malformation
MULTIPLE CHOICE
1. What occurrence results from obstruction within the ventricles of the brain or inadequate reabsorption of
cerebrospinal fluid?
a. Meningitis
b. Meningocele
c. Spina bifida occulta
d. Hydrocephalus
ANS: D
Hydrocephalus is characterized by an increase in cerebrospinal fluid in the ventricles of the brain.
DIF: Cognitive Level: Knowledge REF: Page 329
TOP: Hydrocephalus KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. The nurse is caring for an infant with hydrocephalus. What nursing action is most important for this nurse to
implement?
a. Align the limbs.
b. Support the head.
c. Keep the head lower than the hip.
d. Check intake and output.
ANS: B
The child with hydrocephalus has a heavy head on a small body with poor muscle tone; the head must be
supported when feeding and moving the childNURSINGTB.COM
to prevent injury to the neck.
DIF: Cognitive Level: Application REF: Page 331
TOP: Hydrocephalus KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
3. The nurse observes that the infants anterior fontanelle is bulging after placement of a ventriculoperitoneal
shunt. How should the nurse position this infant?
a. Prone, with the head of the bed elevated
b. Supine, with the head flat
c. Side-lying on the operative side
d. In a semi-Fowlers position
ANS: D
If the fontanelles are bulging, the child will be positioned in a semi-Fowlers position to promote drainage from
the ventricles through the shunt.
DIF: Cognitive Level: Application REF: Page 331
OBJ: 4 TOP: Hydrocephalus
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
4. What nursing action will the nurse implement after feeding an infant with hydrocephalus?
a. Position the infant sitting upright in an infant seat.
b. Place the infant over the shoulder to burp.
c. Leave the infant in a side-lying position.
d. Stimulate the infant by rubbing its feet.
ANS: C
Because children with hydrocephalus are prone to vomiting, the child is fed and then positioned in the side-
NURSINGTB.COM
, INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK
Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 126
lying position in a quiet atmosphere to reduce the incidence of vomiting.
DIF: Cognitive Level: Application REF: Page 331
TOP: Feeding a Hydrocephalic Child KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
5. A newborn was just admitted to the neonatal intensive care unit with a meningomyelocele. What is the
priority preoperative nursing care of this newborn?
a. Keep the sac dry.
b. Diaper snugly.
c. Position prone in an incubator.
d. Move from side to side every hour.
ANS: C
The infant is placed prone in a humidified incubator, and the sac is covered with dressings of sterile saline. The
infants hips are kept lower than the lesion, and the infant is usually not in diapers.
DIF: Cognitive Level: Analysis REF: Page 333
TOP: Myelodysplasia and Spina Bifida KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
6. The nurse is caring for a child who has had a ventriculoperitoneal shunt (VP) for hydrocephalus and
observes an increasing abdominal girth. What is the most appropriate response?
a. Elevate the childs head.
b. Check bowel sounds.
c. Record retention of feeding.
d. Notify the charge nurse of possible malabsorption.
ANS: D
An increasing abdominal girth in a child with NURSINGTB.COM
a VP shunt may be indicative of malabsorption of the
cerebrospinal fluid (CSF) that is being shunted to the peritoneum.
DIF: Cognitive Level: Application REF: Page 331
OBJ: 6 TOP: VP Shunt KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
7. The nurse is providing education to parents of a child with cleft palate. What will the nurse instruct the
parents to report immediately?
a. Facial paralysis
b. Ear infections
c. Increasing intracranial pressure (ICP)
d. Drooling
ANS: B
Children with cleft palate are at risk of ear infections and dental disorders. Parents should be instructed to take
the child to the health care provider at the first sign of earache.
DIF: Cognitive Level: Application REF: Page 336
TOP: Complication of Cleft Palate KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
8. Postoperative nursing care of the infant following surgical repair of a cleft lip would include:
a. Feeding the infant with a spoon to avoid sucking
b. Positioning the infant on the abdomen to facilitate drainage
c. Applying elbow restraints to protect the surgical area
d. Providing minimal stimulation to prevent injury to the incision
ANS: C
Elbow restraints are used postoperatively to prevent the infant from damaging the operative area.
NURSINGTB.COM
