A 2-day-old infant with hydrocephalus returns from surgery following placement of a ventriculoperitoneal shunt. Which nursing intervention(s) should the practical nurse (PN) implement during postoperative care? (Select all that apply.)
Measure head circumference dally.
Document strict intake and output.
Irrigate shunt and pump valve every 12-hours.
Monitor body temperature every 4-hours.
Correct Answer : A,B,D
A. Measure head circumference daily. - Monitoring head circumference is crucial to detect changes that might indicate increased intracranial pressure after the shunt placement.
B. Document strict intake and output. - Monitoring fluid intake and output helps assess the infant's hydration status and shunt functionality.
C. Irrigate shunt and pump valve every 12-hours. - Shunt irrigation should be performed by specialized healthcare professionals, not typically by a practical nurse.
D. Monitor body temperature every 4 hours. - Postoperative monitoring includes assessing for signs of infection or systemic changes, which might be indicated by changes in body temperature.
E. Place in Trendelenburg position. - The Trendelenburg position is not typically recommended post-ventriculoperitoneal shunt placement and should be avoided unless specifically prescribed by the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Observing the method of temperature measurement by the UAP helps identify any incorrect technique or error in obtaining readings.
B. Returning the thermometer for recalibration assumes the issue is with the equipment, which might not be the case.
C. Showing the UAP how to chart temperatures assumes the problem is with documentation, not measurement.
D. Demonstrating how to use the equipment might not address the specific error observed in temperature readings.
Correct Answer is B
Explanation
A. Gravida (G) refers to the total number of pregnancies. This option counts all four pregnancies (twins, son, fetal loss) which is correct. Parity (P) refers to the number of pregnancies that have reached viable gestational age (20 weeks or beyond). Since the fetal loss at 24 weeks is included in the count, the parity is incorrectly stated as 4.
B. Gravida (G) counts all four pregnancies, which is accurate. Parity (P) considers only the pregnancies that reached viable gestational age. As there are two children from the twins, one child aged 4 years, and the fetal loss at 24 weeks (which is not considered as viable gestational age), the correct parity is 3.
C. Gravida (G) represented as 'S' typically indicates "stillbirths" rather than the total number of pregnancies. It does not provide an accurate representation of all pregnancies, so this is not the correct choice.
D. Gravida (G) counts five pregnancies, which doesn't accurately represent the scenario as there have been four pregnancies, not five. Parity (P) as 2 doesn't account for the twins, so it's incorrect.
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