[{"data":1,"prerenderedAt":64},["ShallowReactive",2],{"q-nurse-108-2-maternal-pediatric-062":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":33,"lastmod":63},"產兒科護理學","maternal-pediatric",{"id":7,"webId":8,"year":9,"session":10,"subject":4,"number":11,"stem":12,"options":13,"answer":18,"answerNote":19,"images":20,"explanation":21,"explanationDeep":22,"topics":23,"freq":26},"nurse-108-2-產兒科護理學-062","nurse-108-2-maternal-pediatric-062",108,2,62,"彤彤，因母親懷孕 30 週時突然破水致早產，出生體重 1020 公克，併有腦室內出血（intraventricular hemorrhage, IVH），下列護理措施，何者錯誤？",{"A":14,"B":15,"C":16,"D":17},"抬高床頭 15～20 度，以減少顱內壓","密切監測出血徵狀，如血壓降低、血比容下降","觀察是否出現囪門膨出、頭圍增加等顱內壓升高現象","限制家屬探訪，避免造成感染","D",null,[],"本題考點為早產兒腦室內出血（IVH）的照護重點與顱內壓管理。依 IVH 病生理，出血會使顱內壓升高，故護理著重降壓與監測出血、觀察顱內壓徵象。A 抬高床頭 15～20 度利用重力促進靜脈回流、降低顱內壓，正確；B 監測血壓下降、血比容下降可早期發現持續出血，正確；C 觀察囪門膨出、頭圍增加是嬰兒顱內壓升高的典型指標，正確。錯在 D：IVH 屬缺氧與血管脆弱造成的出血，並非外來感染所致，限制家屬探訪既無法預防 IVH，也剝奪親子連結與安撫，反而不利，故 D 為錯誤措施，選 D。","IVH 好發於 32 週前、體重＜1500g 早產兒，源自腦室旁生發基質（germinal matrix）微血管未成熟且缺乏支持組織，遇缺氧、血壓波動即破裂，依嚴重度分 I～IV 級。照護核心是「維持血流動力學穩定」：減少頭部劇烈轉動、集中護理、避免快速靜脈輸注與抽吸造成壓力波動。記憶法：IVH 三防＝防壓（抬頭正中位）、防血（監測血比容）、防波動（minimal handling）。感染防護屬一般早產兒措施，但與 IVH 病因無直接關聯。",[24,27,29,31],{"term":25,"count":26},"腦室內出血 IVH",1,{"term":28,"count":26},"顱內壓升高徵象",{"term":30,"count":26},"早產兒生發基質",{"term":32,"count":26},"囪門膨出",[34,38,43,48,53,58],{"webId":35,"stem":36,"number":37,"year":9,"session":10},"nurse-108-2-maternal-pediatric-063","有關新生兒壞死性腸炎之敘述，下列何者錯誤？",63,{"webId":39,"stem":40,"number":41,"year":42,"session":26},"nurse-109-1-maternal-pediatric-079","有關先天性巨結腸症（congenital megacolon）之臨床表徵，下列敘述何者錯誤？",79,109,{"webId":44,"stem":45,"number":46,"year":47,"session":26},"nurse-110-1-maternal-pediatric-013","李女士待產時宮縮疼痛非常焦慮不安，下列護理措施何者錯誤？",13,110,{"webId":49,"stem":50,"number":51,"year":52,"session":26},"nurse-111-1-maternal-pediatric-051","正常新生兒消化系統特徵的敘述，下列何者錯誤？",51,111,{"webId":54,"stem":55,"number":56,"year":57,"session":10},"nurse-112-2-maternal-pediatric-015","高女士，G 2 P 0 ，懷孕 38 週，因規則陣痛且自然破水而入院待產。待產期間沒有接受硬脊膜外麻醉，已入院待產 13 小時，目前子宮收縮每 2～3 分鐘一次，持續 50 秒，子宮頸口擴張 8 公分，胎兒高度 −1。請問，高女士此時最不可能出現下列何種徵象或行為反應？",15,112,{"webId":59,"stem":60,"number":61,"year":62,"session":10},"nurse-113-2-maternal-pediatric-029","奇奇，2 歲，因為住院而出現分離焦慮，為了協助奇奇宣洩負向情緒，下列何種治療性遊戲較合適？",29,113,"2026-09-04",1788510707345]