The primary fetal risk when the mother has any type of anemia is for:

Correct Answer: D

Rationale: In the context of maternal diseases during pregnancy, understanding the primary fetal risks associated with specific conditions is crucial for healthcare providers. In the case of anemia in the mother, the primary fetal risk is reduced oxygen delivery, which is best represented by option D. Anemia in the mother leads to a decreased ability to transport oxygen to the fetus, potentially resulting in fetal hypoxia and its associated complications. Option A, neonatal anemia, is incorrect because the focus of the question is on the fetal risks, not the neonatal risks that occur after birth. Option B, elevated bilirubin level, is not directly related to anemia in the mother and is more commonly associated with conditions such as hemolytic disease of the newborn. Option C, limited infection defenses, is also not directly linked to maternal anemia and is more associated with conditions affecting the immune system. Educationally, understanding the impact of maternal health on fetal well-being is essential in obstetric care. Anemia in the mother can have profound effects on the developing fetus, underscoring the importance of early detection and management of maternal conditions during pregnancy to optimize outcomes for both mother and baby. The correct answer, reduced oxygen delivery, highlights the critical role of oxygen in fetal development and the potential consequences of inadequate oxygen supply to the fetus in the presence of maternal anemia.

Correct Answer: A

Rationale: The correct answer is A) Avoid all intramuscular injections until 1 month of age. This is the correct injection technique for infants of mothers who are known carriers of hepatitis B virus because newborns of HBV-positive mothers should receive both the hepatitis B vaccine and hepatitis B immune globulin (HBIG) within 12 hours of birth, followed by the vaccine series. Giving intramuscular injections to these infants can increase the risk of transmission of the virus, as HBV is a bloodborne pathogen. Option B) Diluting intramuscular injections with added normal saline is incorrect because dilution does not mitigate the risk of HBV transmission. Option C) Mixing all injections that the infant will need in a single syringe is incorrect as it can lead to contamination and inaccurate dosing. Option D) Bathing the area where the infant will receive injections is irrelevant to preventing HBV transmission and does not address the specific risk posed by intramuscular injections in HBV-positive infants. In an educational context, understanding the correct injection technique for infants born to HBV-positive mothers is crucial for healthcare providers working in maternal and child health settings to prevent the transmission of infectious diseases. Implementing proper protocols in such cases can significantly impact the health outcomes of newborns at risk.

Correct Answer: B

Rationale: In caring for an infant with hydrocephalus, the most important nursing action is option B) Support the head. Infants with hydrocephalus have an accumulation of cerebrospinal fluid in the brain, causing increased pressure that can lead to head enlargement and potential neurological complications. Supporting the head is crucial to prevent further damage to the delicate brain tissue and to ensure proper alignment of the spine. Option A) Align the limbs, while important for overall positioning and comfort, is not the priority in this case. Option C) Keep the head lower than the hip is incorrect because in hydrocephalus, maintaining the head in a neutral or slightly elevated position can help with cerebral perfusion and reduce intracranial pressure. Option D) Check intake and output is also essential but not the most immediate action needed for a child with hydrocephalus. Educationally, understanding the pathophysiology of hydrocephalus and the specific care needs of these infants is vital for nurses providing care in pediatric settings. Prioritizing interventions based on the condition's acuity and potential complications is key to ensuring optimal outcomes for these vulnerable patients.

Correct Answer: D

Rationale: Rationale: The correct response is option D) Notify the charge nurse of possible malabsorption. An increasing abdominal girth in a child with a ventriculoperitoneal shunt for hydrocephalus could indicate shunt malfunction, leading to increased intracranial pressure and subsequent hydrocephalus. Malabsorption may result from inadequate absorption of nutrients due to increased intracranial pressure affecting gastrointestinal function. This can lead to poor growth and development in the child. Option A) Elevating the child's head is not the priority in this situation as it does not address the potential underlying issue of shunt malfunction and malabsorption. Option B) Checking bowel sounds is important for gastrointestinal assessment but may not directly address the specific concern of increasing abdominal girth related to shunt malfunction. Option C) Recording retention of feeding does not address the urgent need to investigate and address the potential complications associated with the VP shunt and its impact on the child's overall health. In an educational context, understanding the complications associated with VP shunts and their potential effects on various body systems is crucial for nurses caring for pediatric patients with hydrocephalus. Recognizing signs of shunt malfunction early and taking appropriate action can prevent serious consequences and improve patient outcomes. Regular monitoring and prompt reporting of changes in the child's condition are essential in providing safe and effective care.

Correct Answer: A

Rationale: In the context of infants with a surgical repair for a cleft lip, the correct answer is A) "We are feeding the baby with a dropper for 2 weeks." This statement indicates that the parents understand the specific feeding technique required for an infant with a cleft lip. This method allows for controlled feeding and reduces the risk of aspiration, ensuring the baby receives adequate nutrition while minimizing potential complications. Using a dropper helps regulate the flow of milk and prevents it from entering the nasal cavity, which can be a concern post-surgery. Option B) "We resumed bottle feeding after discharge" is incorrect because bottle feeding may not be suitable for infants with a cleft lip due to the risk of milk entering the nasal cavity. Option C) "We started the baby on solid food yesterday" is incorrect as solid foods are not appropriate for an infant who has undergone cleft lip surgery and would pose a choking hazard. Option D) "The baby is drinking well from a straw" is incorrect as using a straw may not be the recommended feeding method for infants with a cleft lip, as it can lead to difficulty in controlling the flow of liquid and increase the risk of aspiration. Educationally, understanding the appropriate feeding techniques for infants with specific conditions like cleft lip is crucial for healthcare providers and parents to ensure optimal care and support for the infant's health and well-being. Parents must be educated on proper feeding techniques to prevent complications and promote the infant's growth and development.