[{"data":1,"prerenderedAt":63},["ShallowReactive",2],{"q-nurse-110-2-maternal-pediatric-078":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":33,"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":26},"nurse-110-2-產兒科護理學-078","nurse-110-2-maternal-pediatric-078",110,2,78,"小玉，3 歲，因原有腦室-腹膜分流管（V-P shunt）感染，已移除並接受腦室外引流（external ventricular drainage）手術，有關術後護理措施，下列敘述何者正確？",{"A":14,"B":15,"C":16,"D":17},"引流時需完全平躺，以眼睛高度為壓力零點，嚴禁抬高床頭","此裝置可配合測量顱內壓","只能採取持續性引流，不可關閉引流管","將腦脊髓液引流至一個半開放式的無菌收集瓶","B",null,[],"本題考點是腦室外引流(EVD)術後的護理原則。考點在於EVD兼具引流腦脊髓液與監測顱內壓的功能，且引流高度須以固定解剖參考點為零點。選項B「此裝置可配合測量顱內壓」正確，EVD可連接壓力轉能器監測顱內壓，故為答案。A「需完全平躺、以眼睛高度為零點、嚴禁抬高床頭」錯誤，零點通常定於外耳道或Monro孔而非眼睛，且床頭多維持適度抬高；C「只能持續引流、不可關閉」錯誤，可依醫囑間歇引流或暫時夾管(如翻身、搬運時);D「引流至半開放式收集瓶」錯誤，應為密閉無菌系統以防感染。故唯B正確。","腦室外引流用於暫時引流腦脊髓液、降顱內壓並可監測壓力。零點參考:外耳道(相當於Monro孔\u002F側腦室高度);引流袋高度依醫囑設定以控制引流量，過低引流過多致低顱內壓與腦室塌陷。護理:維持密閉無菌、翻身搬運先夾管、記錄引流量色澤、監測感染與顱內壓變化。記憶:零點在耳道、搬動先夾管、系統要密閉。可連結:V-P分流管感染時常先改EVD過渡;過度引流風險與硬膜下出血。",[24,27,29,31],{"term":25,"count":26},"腦室外引流",1,{"term":28,"count":26},"顱內壓監測",{"term":30,"count":26},"引流零點",{"term":32,"count":26},"密閉無菌系統",[34,38,43,48,53,58],{"webId":35,"stem":36,"number":37,"year":9,"session":10},"nurse-110-2-maternal-pediatric-079","陳小妹，於學校上體育課時，出現強直陣攣型痙攣（tonic-clonic seizure）發作，下列護理措施何者最不適當？",79,{"webId":39,"stem":40,"number":41,"year":42,"session":10},"nurse-111-2-maternal-pediatric-015","根據世界衛生組織（WHO）對無併發症或任何健康問題婦女的待產期照護建議，下列何者正確？",15,111,{"webId":44,"stem":45,"number":46,"year":47,"session":26},"nurse-112-1-maternal-pediatric-029","正常新生兒出生 4～6 小時內，最主要的能量來源為何？",29,112,{"webId":49,"stem":50,"number":51,"year":52,"session":26},"nurse-113-1-maternal-pediatric-017","抱起新生兒放入磅秤測量體重，新生兒四肢出現對稱性的外展和伸直，大拇指與食指呈C字形，是下列那種反射表現？",17,113,{"webId":54,"stem":55,"number":56,"year":57,"session":10},"nurse-114-2-maternal-pediatric-021","王女士，產後第 4 天哺餵母乳中，左小腿出現明顯疼痛，靜脈血管攝影檢測後確診為深層血栓靜脈炎。有關身體評估與臨床處置的敘述，下列何者正確？",21,114,{"webId":59,"stem":60,"number":41,"year":61,"session":26},"nurse-106-1-maternal-pediatric-015","張女士待產時胎心率發生變異性減速（variable deceleration），此時護理師應最先執行的護理措施為下列那一項？",106,"2026-09-04",1788510730371]