Chapter 30: The Child with Neuromuscular or Muscular Dysfunction

1. The nurse is planning a staff in-service on childhood spastic cerebral palsy. What

characterizes spastic cerebral palsy?

a. Hypertonicity and poor control of posture, balance, and coordinated motion

b. Athetosis and dystonic movements

c. Wide-based gait and poor performance of rapid, repetitive movements

d. Tremors and lack of active movement

ANS: A

Hypertonicity and poor control of posture, balance, and coordinated motion are part of the classification

of spastic cerebral palsy. Athetosis and dystonic movements are part of the classification of dyskinetic

(athetoid) cerebral palsy. Wide-based gait and poor performance of rapid, repetitive movements are part

of the classification of ataxic cerebral palsy. Tremors and lack of active movement may indicate other

neurologic disorders.

DIF: Cognitive Level: Understand REF: p. 978

TOP: Integrated Process: Teaching/Learning

MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

2. The parents of a child with cerebral palsy ask the nurse whether any drugs can decrease

their child's spasticity. The nurse's response should be based on which statement?

a. Anticonvulsant medications are sometimes useful for controlling spasticity.

b. Medications that would be useful in reducing spasticity are too toxic for use with

children.

c. Many different medications can be highly effective in controlling spasticity.

d. Implantation of a pump to deliver medication into the intrathecal space to decrease

spasticity has recently become available.

ANS: D

Baclofen, given intrathecally, is best suited for children with severe spasticity that interferes with

activities of daily living and ambulation. Anticonvulsant medications are used when seizures occur in

children with cerebral palsy. The intrathecal route decreases the side effects of the drugs that reduce

spasticity. Few medications are currently available for the control of spasticity.

DIF: Cognitive Level: Understand REF: p. 979

TOP: Integrated Process: Teaching/Learning

MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

9. The nurse is talking to a parent with a child who has a latex allergy. Which statement by

the parent would indicate a correct understanding of the teaching?

a. "My child will have an allergic reaction if he comes in contact with yeast products."

b. "My child may have an upset stomach if he eats a food made with wheat or barley."

c. "My child will probably develop an allergy to peanuts."

d. "My child should not eat bananas or kiwis."

d. "My child should not eat bananas or kiwis."

ANS: D

There are cross-reactions between latex allergies and a number of foods such as bananas, avocados, kiwi,

and chestnuts. Children with a latex allergy will not develop allergies to other food products such as

yeast, wheat, barley, or peanuts.

DIF: Cognitive Level: Analyze REF: p. 990

TOP: Integrated Process: Nursing Process: Evaluation

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10. Latex allergy is suspected in a child with spina bifida. Appropriate nursing interventions include which action?

a. Avoid using any latex product.

b. Use only nonallergenic latex products.

c. Administer medication for long-term desensitization.

d. Teach family about long-term management of asthma.

a. Avoid using any latex product.

ANS: A

Care must be taken that individuals who are at high risk for latex allergies do not come in direct or

secondary contact with products or equipment containing latex at any time during medical treatment.

There are no nonallergenic latex products. At this time, desensitization is not an option. The child does

not have asthma. The parents must be taught about allergy and the risk of anaphylaxis.

DIF: Cognitive Level: Apply REF: p. 990

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13. A 4-year-old child has just been diagnosed with pseudohypertrophic (Duchenne)

muscular dystrophy. The management plan should include which action?

a. Recommend genetic counseling.

b. Explain that the disease is easily treated.

c. Suggest ways to limit use of muscles.

d. Assist family in finding a nursing facility to provide child's care.

a. Recommend genetic counseling.

ANS: A

Pseudohypertrophic (Duchenne) muscular dystrophy is inherited as an X-linked recessive gene. Genetic

counseling is recommended for parents, female siblings, maternal aunts, and their female offspring. No

effective treatment exists at this time for childhood muscular dystrophy. Maintaining optimal function of

all muscles for as long as possible is the primary goal. It has been found that children who remain as

active as possible are able to avoid wheelchair confinement for a longer time. Assisting the family in

finding a nursing facility to provide the child's care is inappropriate at the time of diagnosis. When the

child becomes increasingly incapacitated, the family may consider home-based care, a skilled nursing

facility, or respite care to provide the necessary care.

DIF: Cognitive Level: Understand REF: p. 992

TOP: Integrated Process: Nursing Process: Implementation

MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

1. A 14-year-old girl is in the intensive care unit after a spinal cord injury 2 days ago.

Nursing care for this child includes which action(s)? (Select all that apply.)

a. Monitoring and maintaining systemic blood pressure

b. Administering corticosteroids

c. Minimizing environmental stimuli

d. Discussing long-term care issues with the family

e. Monitoring for respiratory complications

ANS: A, B, E

Spinal cord injury patients are physiologically labile, and close monitoring is required. They may be

unstable for the first few weeks after the injury. Corticosteroids are administered to minimize the

inflammation present with the injury. It is not necessary to minimize environmental stimuli for this type

of injury. Discussing long-term care issues with the family is inappropriate. The family is focusing on the

recovery of their child. It will not be known until the rehabilitation period how much function the child

may recover.

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2. Which assessment findings should the nurse note in a school-age child with Duchenne muscular dystrophy (DMD)? (Select all that apply.)

a. Lordosis

b. Gower sign

c. Kyphosis

d. Scoliosis

e. Waddling gait

ANS: A, B, E

Difficulties in running, riding a bicycle, and climbing stairs are usually the first symptoms noted in

Duchenne muscular dystrophy. Typically, affected boys have a waddling gait and lordosis, fall frequently,

and develop a characteristic manner of rising from a squatting or sitting position on the floor (Gower

sign). Lordosis occurs as a result of weakened pelvic muscles, and the waddling gait is a result of

weakness in the gluteus medius and maximus muscles. Kyphosis and scoliosis are not assessment

findings with DMD.

DIF: Cognitive Level: Apply REF: p. 992

TOP: Integrated Process: Nursing Process: Assessment

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What is a clinical manifestation of increased intracranial pressure (ICP) in infants?

a. Irritability

b. Photophobia

c. Vomiting and diarrhea

d. Pulsating anterior fontanel

A

What is included in the assessment for the Glasgow Coma Scale?

a. Pupil reactivity and motor response

b. Level of consciousness and verbal response

c. Eye opening and verbal and motor response

d. Intracranial pressure and level of consciousness

C

The nurse is doing a neurologic assessment on a child whose level of consciousness has been variable since sustaining a cervical neck injury 12 hr ago. What is the most essential in this assessment?

a. Reactivity of pupils

b. Doll's head maneuver

c. Oculovestibular response

d. Funduscopic examination to identify papilledema

A

The nurse is caring for a child with multiple injuries who is comatose. What information is accurate related to pain in this child?

a. Cannot occur if the child is comatose.

b. May occur if the child regains consciousness.

c. Requires astute nursing assessment and management.

d. Is best assessed by family members who are familiar with the child.

C

The nurse is caring for a 2-year-old girl who is unconscious but stable after a car accident. Her parents are staying at the bedside most of the time. What is an appropriate nursing intervention?

a. Suggest that the parents go home until she is alert enough to know they are present.

b. Encourage the parents to hold, talk, and sing to her as they usually would.

c. Use ointment on her lips but do not attempt to cleanse her teeth until swallowing returns.

d. Position her with proper body alignment and the head of the bed lowered 15 degrees.

B

Why are infants particularly vulnerable to acceleration-deceleration head injuries?

a. The anterior fontanel is not yet closed.

b. The nervous tissue is not well developed.

c. The scalp of the head has extensive vascularity.

d. Musculoskeletal support of the head is insufficient.

D

What findings would indicate to the nurse further assessment and treatment is needed for a child with mild head injury?

a. Vomiting

b. Sleepiness

c. Headache, even if slight

d. Confusion or abnormal behavior

D

A 3-year-old child is hospitalized after submersion injury. The child's mother complains to the nurse, "This seems unnecessary when he is perfectly fine." What is the appropriate response by the nurse?

a. "He still needs a little extra oxygen."

b. "I'm sure he is fine, but the doctor wants to make sure."

c. "It is important to observe for possible physical reasons for the accident."

d. "The reason for hospitalization is that complications could still occur."

D

The nurse is admitting a young child to the hospital because bacterial meningitis is suspected. What is a priority of nursing care?

a. Initiate isolation precautions as soon as diagnosis is confirmed.

b. Provide environmental stimulation to keep the child awake.

c. Administer antibiotic therapy as soon as it is available.

d. Administer sedatives and analgesics on a preventive schedule to manage pain.

C

A child is brought to the emergency department after experiencing a seizure at school. He has no history of seizures. The father tells the nurse that he cannot believe the child has epilepsy. What is the best response by the nurse?

a. "Epilepsy is easily treated."

b. "Very few children have actual epilepsy."

c. "The seizure may or may not mean that your child has epilepsy."

d. "Your child has had only one convulsion; it probably won't happen again."

C

The nurse is reviewing prenatal vitamin supplements with an expectant client. Which

supplement should be included in the teaching?

a. Vitamin A throughout pregnancy

b. Multivitamin preparations as soon as pregnancy is suspected

c. Folic acid for all women of childbearing age

d. Folic acid during the first and second trimesters of pregnancy

c. Folic acid for all women of childbearing age

ANS: C

The widespread use of folic acid among women of childbearing age has decreased the incidence of spina

bifida significantly. Vitamin A is not related to the prevention of spina bifida. Folic acid supplementation

is recommended for the preconception period and during the pregnancy. Only 42% of women actually

follow these guidelines.

DIF: Cognitive Level: Understand REF: p. 988

TOP: Integrated Process: Nursing Process: Implementation

MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

Which clinical manifestations in an infant would be suggestive of spinal muscular

atrophy (Werdnig-Hoffmann disease)?

a. Hyperactive deep tendon reflexes

b. Hypertonicity

c. Lying in the frog position

d. Motor deficits on one side of body

c. Lying in the frog position

The nurse is conducting reflex testing on infants at a well-child clinic. Which reflex

finding should be reported as abnormal and considered as a possible sign of cerebral palsy?

a. Tonic neck reflex at 5 months of age

b. Absent Moro reflex at 8 months of age

c. Moro reflex at 3 months of age

d. Extensor reflex at 7 months of age

d. Extensor reflex at 7 months of age

ANS: D

Establishing a diagnosis of cerebral palsy (CP) may be confirmed with the persistence of primitive

reflexes: (1) either the asymmetric tonic neck reflex or persistent Moro reflex (beyond 4 months of age)

and (2) the crossed extensor reflex. The tonic neck reflex normally disappears between 4 and 6 months of

age. The crossed extensor reflex, which normally disappears by 4 months, is elicited by applying a

noxious stimulus to the sole of one foot with the knee extended. Normally, the contralateral foot responds

with extensor, abduction, and then adduction movements. The possibility of CP is suggested if these

reflexes occur after 4 months.

DIF: Cognitive Level: Apply REF: p. 979

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The nurse is admitting a school-age child with suspected Guillain-Barré syndrome

(GBS). Which is a priority in the care for this child?

a. Monitoring intake and output

b. Assessing respiratory efforts

c. Placing on a telemetry monitor

d. Obtaining laboratory studies

b. Assessing respiratory efforts

ANS: B

Treatment of GBS is primarily supportive. In the acute phase, patients are hospitalized because

respiratory and pharyngeal involvement may require assisted ventilation, sometimes with a temporary

tracheotomy. Treatment modalities include aggressive ventilatory support in the event of respiratory

compromise, intravenous (IV) administration of immunoglobulin (IVIG), and sometimes steroids;

plasmapheresis and immunosuppressive drugs may also be used. Intake and output, telemetry monitoring,

and obtaining laboratory studies may be part of the plan of care but are not the priority.

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Which should the nurse expect to find in the cerebral spinal fluid (CSF) results of a

child with Guillain-Barré syndrome (GBS)? (Select all that apply.)

a. Decreased protein concentration

b. Normal glucose

c. Fewer than 10 white blood cells (WBCs/mm3)

d. Elevated red blood cell (RBC) count

b. Normal glucose

c. Fewer than 10 white blood cells (WBCs/mm3)

ANS: B, C

Diagnosis of GBS is based on clinical manifestations, CSF analysis, and EMG findings. CSF analysis

reveals an abnormally elevated protein concentration, normal glucose, and fewer than 10 WBCs/mm3

.

CSF fluid should not contain RBCs.

DIF: Cognitive Level: Understand REF: p. 996

TOP: Integrated Process: Nursing Process: Evaluation

MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

3. The nurse is preparing to admit a newborn with myelomeningocele to the neonatal

intensive care nursery. Which describes this newborn's defect?

a. Fissure in the spinal column that leaves the meninges and the spinal cord exposed

b. Herniation of the brain and meninges through a defect in the skull

c. Hernial protrusion of a saclike cyst of meninges with spinal fluid but no neural

elements

d. Visible defect with an external saclike protrusion containing meninges, spinal fluid,

and nerves

d. Visible defect with an external saclike protrusion containing meninges, spinal fluid,

and nerves

ANS: D

A myelomeningocele is a visible defect with an external saclike protrusion, containing meninges, spinal

fluid, and nerves. Rachischisis is a fissure in the spinal column that leaves the meninges and the spinal

cord exposed. Encephalocele is a herniation of brain and meninges through a defect in the skull,

producing a fluid-filled sac. Meningocele is a hernial protrusion of a saclike cyst of meninges with spinal

fluid, but no neural elements.

4. The nurse is conducting a staff in-service on common problems associated with

myelomeningocele. Which common problem is associated with this defect?

a. Hydrocephalus

b. Craniostenosis

c. Biliary atresia

d. Esophageal atresia

ANS: A

Hydrocephalus is a frequently associated anomaly in 80% to 90% of children. Craniostenosis is the

preterm closing of the cranial sutures and is not associated with myelomeningocele. Biliary and

esophageal atresia is not associated with myelomeningocele.

DIF: Cognitive Level: Understand REF: p. 984

TOP: Integrated Process: Teaching/Learning

MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

5. The nurse is teaching a group of nursing students about newborns born with the

congenital defect of myelomeningocele. Which common problem is associated with this defect?

a. Neurogenic bladder

b. Cognitive impairment

c. Respiratory compromise

d. Cranioschisis

a. Neurogenic bladder

ANS: A

Myelomeningocele is one of the most common causes of neuropathic (neurogenic) bladder dysfunction

among children. Risk of cognitive impairment is minimized through early intervention and management

of hydrocephalus. Respiratory compromise is not a common problem in myelomeningocele. Cranioschisis

is a skull defect through which various tissues protrude. It is not associated with myelomeningocele.

DIF: Cognitive Level: Understand REF: p. 987

TOP: Integrated Process: Teaching/Learning

MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

7. How much folic acid is recommended for women of childbearing age?

a. 1.0 mg

b. 0.4 mg

c. 1.5 mg

d. 2.0 mg

b. 0.4 mg

ANS: B

It has been estimated that a daily intake of 0.4 mg of folic acid in women of childbearing age will prevent

50% to 70% of cases of neural tube defects; 1.0 mg is too low a dose; 1.5 to 2.0 mg are not the

recommended dosages of folic acid.

DIF: Cognitive Level: Remember REF: p. 988

TOP: Integrated Process: Nursing Process: Evaluation

MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

8. The nurse is caring for a neonate born with a myelomeningocele. Surgery to repair the

defect is scheduled the next day. Which describes the most appropriate way to position and feed

this neonate?

a. Prone and tube-fed

b. Prone, head turned to side, and nipple-fed

c. Supine in an infant carrier and nipple-fed

d. Supine, with defect supported with rolled blankets, and nipple-fed

b. Prone, head turned to side, and nipple-fed

ANS: B

In the prone position, feeding is a problem. The infant's head is turned to one side for feeding. If the child

is able to nipple-feed, tube feeding is not needed. Before surgery, the infant is kept in the prone position

to minimize tension on the sac and risk of trauma.

DIF: Cognitive Level: Apply REF: p. 988

TOP: Integrated Process: Nursing Process: Implementation

MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort

11. The nurse is admitting a child with Werdnig-Hoffmann disease (spinal muscular

atrophy type 1). Which signs and symptoms are associated with this disease?

a. Spinal muscular atrophy

b. Neural atrophy of muscles

c. Progressive weakness and wasting of skeletal muscle

d. Pseudohypertrophy of certain muscle groups

c. Progressive weakness and wasting of skeletal muscle

ANS: C

Werdnig-Hoffmann disease (spinal muscular atrophy type 1) is the most common paralytic form of floppy

infant syndrome (congenital hypotonia). It is characterized by progressive weakness and wasting of

skeletal muscle caused by degeneration of anterior horn cells. Kugelberg-Welander disease is a juvenile

spinal muscular atrophy with a later onset. Charcot-Marie-Tooth disease is a form of progressive neural

atrophy of muscles supplied by the peroneal nerves. Progressive weakness is found of the distal muscles

of the arms and feet. Duchenne muscular dystrophy is characterized by muscles, especially in the calves,

thighs, and upper arms, which become enlarged from fatty infiltration and feel unusually firm or woody

on palpation. The term pseudohypertrophy is derived from this muscular enlargement.

DIF: Cognitive Level: Understand REF: p. 991

TOP: Integrated Process: Nursing Process: Assessment

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14. What should be administered to a child with tetanus?

a. Nonsteroidal antiinflammatory drugs (NSAIDs) to reduce inflammation.

b. Muscle stimulants to counteract muscle weakness.

c. Bronchodilators to prevent respiratory complications.

d. Tetanus immunoglobulin therapy.

d. Tetanus immunoglobulin therapy.

ANS: D

Tetanus immunoglobulin therapy, to neutralize toxins, is the most specific therapy for tetanus. Tetanus

toxin acts at the myoneural junction to produce muscular stiffness and lowers the threshold for reflex

excitability. NSAIDs are not routinely used. Sedatives or muscle relaxants are used to help reduce titanic

spasm and prevent seizures. Respiratory status is carefully evaluated for any signs of distress because

muscle relaxants, opioids, and sedatives that may be prescribed may cause respiratory depression.

Bronchodilators would not be used unless specifically indicated.

DIF: Cognitive Level: Understand REF: p. 997

TOP: Integrated Process: Nursing Process: Implementation

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16. The nurse is caring for an infant with myelomeningocele scheduled for surgical closure

in the morning. Which intervention should the nurse plan for the care of the myelomeningocele

sac?

a. Open to air

b. Covered with a sterile, moist, nonadherent dressing

c. Reinforcement of the original dressing if drainage noted

d. A diaper secured over the dressing

b. Covered with a sterile, moist, nonadherent dressing

ANS: B

Before surgical closure, the myelomeningocele is prevented from drying by the application of a sterile,

moist, nonadherent dressing over the defect. The moistening solution is usually sterile normal saline.

Dressings are changed frequently (every 2 to 4 hours), and the sac is closely inspected for leaks,

abrasions, irritation, and any signs of infection. The sac must be carefully cleansed if it becomes soiled or

contaminated. The original dressing would not be reinforced but changed as needed. A diaper is not

placed over the dressing because stool contamination can occur.

DIF: Cognitive Level: Apply REF: p. 987

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18. The nurse is caring for an intubated infant with botulism in the pediatric intensive care

unit. Which health care provider prescription should the nurse clarify with the health care provider

before implementing?

a. Administer 250 mg botulism immune globulin intravenously (BIG-IV) one time.

b. Provide total parenteral nutrition (TPN) at 25 ml/hr intravenously.

c. Titrate oxygen to keep pulse oximetry saturations greater than 92.

d. Administer gentamicin sulfate (Garamycin) 10 mg per intravenous piggyback every

12 hours.

d. Administer gentamicin sulfate (Garamycin) 10 mg per intravenous piggyback every

ANS: D

The nurse should clarify the administration of an aminoglycoside antibiotic. Antibiotic therapy is not part

of the management of infant botulism because the botulinum toxin is an intracellular molecule, and

antibiotics would not be effective; aminoglycosides in particular should not be administered because they

may potentiate the blocking effects of the neurotoxin. Treatment consists of immediate administration of

botulism immune globulin intravenously (BIG-IV) without delaying for laboratory diagnosis. Early

administration of BIG-IV neutralizes the toxin and stops the progression of the disease. The human-

derived botulism antitoxin (BIG-IV) has been evaluated and is now available nationwide for use only in

infant botulism. Approximately 50% of affected infants require intubation and mechanical ventilation;

therefore, respiratory support is crucial, as is nutritional support, because these infants are unable to feed.

DIF: Cognitive Level: Analyze REF: p. 999

TOP: Integrated Process: Nursing Process: Evaluation

MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

19. A home care nurse is caring for an adolescent with a T1 spinal cord injury. The

adolescent suddenly becomes flushed, hypertensive, and diaphoretic. Which intervention should

the nurse perform first?

a. Place the adolescent in a flat right side-lying position.

b. Place a cool washcloth on the adolescent's forehead and continue to monitor the

blood pressure.

c. Implement a standing prescription to empty the bladder with a sterile in and out

Foley catheter.

d. Take a full set of vital signs and notify the health care provider.

c. Implement a standing prescription to empty the bladder with a sterile in and out

ANS: C

The adolescent is experiencing an autonomic dysreflexia episode. The paralytic nature of autonomic

function is replaced by autonomic dysreflexia, especially when the lesions are above the mid-thoracic

level. This autonomic phenomenon is caused by visceral distention or irritation, particularly of the bowel

or bladder. Sensory impulses are triggered and travel to the cord lesion, where they are blocked, which

causes activation of sympathetic reflex action with disturbed central inhibitory control. Excessive

sympathetic activity is manifested by a flushing face, sweating forehead, pupillary constriction, marked

hypertension, headache, and bradycardia. The precipitating stimulus may be merely a full bladder or

rectum or other internal or external sensory input. It can be a catastrophic event unless the irritation is

relieved. Placing a cool washcloth on the adolescent's forehead, continuing to monitor blood pressure and

vital signs, and notifying the health care provider would not reverse the sympathetic reflex situation.

DIF: Cognitive Level: Apply REF: p. 1000

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20. A child steps on a nail and sustains a puncture wound of the foot. Which is the most

appropriate method for cleansing this wound?

a. Wash wound thoroughly with chlorhexidine.

b. Wash wound thoroughly with povidone-iodine.

c. Soak foot in warm water and soap.

d. Soak foot in solution of 50% hydrogen peroxide and 50% water.

ANS: C

Puncture wounds should be cleansed by soaking the foot in warm water and soap. Chlorhexidine,

hydrogen peroxide, and povidone-iodine should not be used because they have a cytotoxic effect on

healthy cells and minimal effect on controlling infection.

DIF: Cognitive Level: Apply REF: p. 998

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3. The nurse is conducting discharge teaching to parents of a preschool child with

myelomeningocele, repaired at birth, being discharged from the hospital after a urinary tract

infection (UTI). Which should the nurse include in the discharge instructions related to

management of the child's genitourinary function? (Select all that apply.)

a. Continue to perform the clean intermittent catheterizations (CIC) at home.

b. Administer the oxybutynin chloride (Ditropan) as prescribed.

c. Reduce fluid intake in the afternoon and evening hours.

d. Monitor for signs of a recurrent urinary tract infection.

e. Administer furosemide (Lasix) as prescribed.

ANS: A, B, D

Discharge teaching to prevent renal complications in a child with myelomeningocele include: (1) regular

urologic care with prompt and vigorous treatment of infections; (2) a method of regular emptying of the

bladder, such as CIC taught to and performed by parents and self-catheterization taught to children; (3)

medications to improve bladder storage and continence, such as oxybutynin chloride (Ditropan) and

tolterodine (Detrol). Fluids should not be limited and Lasix is not used to improve renal function for

children with myelomeningocele.

DIF: Cognitive Level: Apply REF: p. 984

TOP: Integrated Process: Teaching/Learning

MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

5. The nurse in the neonatal intensive care unit is caring for an infant with

myelomeningocele scheduled for surgical repair in the morning. Which early signs of infection

should the nurse monitor on this infant? (Select all that apply.)

a. Temperature instability

b. Irritability

c. Lethargy

d. Bradycardia

e. Hypertension

ANS: A, B, C

The nurse should observe an infant with unrepaired myelomeningocele for early signs of infection, such

as temperature instability (axillary), irritability, and lethargy. Bradycardia and hypertension are not early

signs of infection in infants.

DIF: Cognitive Level: Analyze REF: p. 989

TOP: Integrated Process: Nursing Process: Evaluation

MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential