[{"data":1,"prerenderedAt":63},["ShallowReactive",2],{"q-nurse-109-1-maternal-pediatric-054":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":32,"lastmod":62},"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":10},"nurse-109-1-產兒科護理學-054","nurse-109-1-maternal-pediatric-054",109,1,54,"協助病童接受腰椎穿刺檢查過程中，下列護理措施何者不恰當？",{"A":14,"B":15,"C":16,"D":17},"穿刺前應仔細評估病童有無顱內壓升高之徵象","穿刺時協助病童採半側臥、頭高腳低的舒適臥位","穿刺前後應監測病童是否有脊髓脫出的症狀產生","穿刺後教導病童平躺以減少頭痛及穿刺部位出血","B",null,[],"本題考點在於腰椎穿刺（LP）的正確擺位與安全評估。依穿刺解剖原理，欲拉開腰椎棘突間隙、方便針頭進入蜘蛛膜下腔，病童應採側臥並將膝蓋屈向胸部呈蝦米狀（胎兒姿勢），而非半側臥、頭高腳低，故 B 的臥位不恰當、為答案。A 穿刺前評估有無顱內壓升高徵象是必要的，因 IICP 為 LP 禁忌，貿然穿刺會因壓力差誘發腦疝。C 前後監測神經與呼吸變化，以偵測腦幹或脊髓受壓，屬合理措施。D 穿刺後採平躺，可降低腦脊髓液滲漏造成的低壓性頭痛並減少穿刺部位出血，符合脊椎穿刺後常規。三者皆恰當，唯 B 擺位錯誤。","口訣：LP 擺位＝側臥＋抱膝＋低頭（C 形彎），把腰椎「拱起來」拉開 L3–L4 或 L4–L5 間隙。頭高腳低會減少下段腦脊髓液壓力，反而不利抽取且擺位不穩。穿刺後平躺去枕的用意是減少腦脊髓液沿針孔外漏、預防姿勢性頭痛；此頭痛坐起加劇、平躺緩解，是低顱壓的典型特徵。",[24,26,28,30],{"term":25,"count":10},"腰椎穿刺擺位",{"term":27,"count":10},"胎兒姿勢\u002F蝦米狀",{"term":29,"count":10},"顱內壓升高為 LP 禁忌",{"term":31,"count":10},"穿刺後低壓性頭痛",[33,37,42,47,52,58],{"webId":34,"stem":35,"number":36,"year":9,"session":10},"nurse-109-1-maternal-pediatric-055","小美，3 歲，因重積癲癇而入住加護病房照護，下列何者不是以家庭為中心的照護？",55,{"webId":38,"stem":39,"number":40,"year":9,"session":41},"nurse-109-2-maternal-pediatric-071","癌症病童接受治療期間，有關疫苗接種之敘述，下列何者最不適當？",71,2,{"webId":43,"stem":44,"number":45,"year":46,"session":41},"nurse-110-2-maternal-pediatric-005","有關產前胎兒生理活動評估，下列敘述何者正確？",5,110,{"webId":48,"stem":49,"number":50,"year":51,"session":41},"nurse-111-2-maternal-pediatric-043","玲玲，2 歲 12 公斤，媽媽自己開車載她看醫生，玲玲乘坐汽車的方式，下列何者正確？",43,111,{"webId":53,"stem":54,"number":55,"year":56,"session":57},"nurse-112-3-maternal-pediatric-007","張女士，G 1 P 0 ，懷孕 40 週，下列何者是真陣痛的特徵？",7,112,3,{"webId":59,"stem":60,"number":10,"year":61,"session":10},"nurse-114-1-maternal-pediatric-001","有關婦嬰生命統計資料的敘述，下列何者錯誤？",114,"2026-09-04",1788510713623]