[{"data":1,"prerenderedAt":62},["ShallowReactive",2],{"q-nurse-111-2-maternal-pediatric-080":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":34,"lastmod":61},"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-111-2-產兒科護理學-080","nurse-111-2-maternal-pediatric-080",111,2,80,"張小弟，5 個月大，因不慎跌落床下，診斷為顱內出血，有顱內壓增高（increase intracranial pressure, IICP）現象，有關其護理措施，下列敘述何者較不適當？",{"A":14,"B":15,"C":16,"D":17},"觀察兒童囟門有無緊繃鼓脹現象，每天測量頭圍","鼓勵父母陪伴，並給予安撫，減少哭泣不安","給予多喝水，增加體液容積以及腦組織灌流","保持床頭抬高約 30～45 度，維持頭部於中線位置，並避免壓迫頸靜脈","C",null,[],"本題考點為顱內壓增高(IICP)嬰兒的護理措施。IICP 處置目標為降低腦水腫與促進靜脈回流,須限制水分而非增加。C 敘述「給予多喝水增加體液容積以及腦組織灌流」是錯誤的,過度補充液體會加重腦水腫與顱內壓,IICP 時應限制液體,故為答案。A 觀察囟門緊繃鼓脹並每天量頭圍,是嬰兒監測 IICP 的重要指標,正確;B 鼓勵父母陪伴安撫、減少哭鬧,因哭泣會使顱內壓上升,正確;D 床頭抬高 30～45 度、頭部維持中線、避免壓迫頸靜脈,可促進腦部靜脈回流降低顱內壓,正確。考點在於掌握 IICP「限水、抬高床頭、減少刺激、促進靜脈回流」的照護原則。","IICP 護理核心:床頭抬高 15～30 度、頭頸中線位以利頸靜脈回流,避免頸部彎曲扭轉;限制液體防腦水腫;減少哭鬧、咳嗽、抽吸等會升高顱內壓的刺激。嬰兒囟門未閉,鼓脹囟門與頭圍增大為 IICP 早期徵象。庫欣三徵(血壓升高、心搏過緩、呼吸不規則)為晚期危險訊號。",[24,27,29,32],{"term":25,"count":26},"顱內壓增高",3,{"term":28,"count":10},"促進靜脈回流",{"term":30,"count":31},"限制液體",1,{"term":33,"count":31},"床頭抬高與頭部中線",[35,39,43,47,52,57],{"webId":36,"stem":37,"number":31,"year":38,"session":31},"nurse-112-1-maternal-pediatric-001","有關分娩期的支持性照護措施，下列何者較不適當？",112,{"webId":40,"stem":41,"number":42,"year":38,"session":10},"nurse-112-2-maternal-pediatric-017","周女士，G 1 P 0 ，懷孕 39 週，因破水且子宮頸口開 3 公分。以臺灣目前臨床實務最常見的電子胎兒監測方式，下列護理師的說明，何者不適當？",17,{"webId":44,"stem":45,"number":46,"year":38,"session":26},"nurse-112-3-maternal-pediatric-031","有關病童使用 Fentanyl 貼片的敘述，下列護理指導何者錯誤？",31,{"webId":48,"stem":49,"number":50,"year":51,"session":31},"nurse-114-1-maternal-pediatric-029","10個月大新生兒進行身體檢查仍會有的反射項目，下列何者最為正確？",29,114,{"webId":53,"stem":54,"number":55,"year":56,"session":10},"nurse-115-2-maternal-pediatric-033","評估嬰兒術後疼痛，下列量表何者最適宜？",33,115,{"webId":58,"stem":59,"number":42,"year":60,"session":31},"nurse-107-1-maternal-pediatric-017","林女士，29 歲，大陸瀋陽人，G 1 P 1 ，先生為臺商，結婚後來臺居住，產後第一天她抱怨沒有奶水無法餵奶，懷孕生產讓自己變胖變醜，先生過兩天後要回大陸工作，必須獨自一人照顧新生兒而顯擔憂。護理師對其產後調適的評估，下列護理問題何者較不恰當？",107,"2026-09-04",1788510739717]