A nurse is assessing a 4-year-old child who is 2 days postoperative following insertion of a ventriculoperitoneal shunt. Which of the following findings is the nurse's priority?

Urine output of 50 mL in 2 hr

Lethargy

Respiratory rate 24/min

Absent Babinski reflex

Answer and Explanation

The Correct Answer is B

A. Urine output of 50 mL in 2 hr: This is within normal limits for a child and does not indicate an immediate concern.
B. Lethargy: Lethargy is a potential sign of increased intracranial pressure (ICP), which is a critical complication of VP shunt placement and requires immediate intervention.
C. Respiratory rate 24/min: This is within the normal range for a 4-year-old child.
D. Absent Babinski reflex: This is a normal finding in children over 2 years old, as the reflex typically disappears by that age.

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Correct Answer is ["A","B","C","F","G","H"]

Explanation

A. Maintain NPO status. The child is at risk for surgery, and maintaining NPO status reduces the risk of aspiration.
B. Administer an antipyretic. Reducing fever can improve comfort and decrease metabolic demand.
C. Initiate an infusion of IV fluids. IV fluids prevent dehydration, especially since the child has had poor oral intake and diarrhea.
D. Administer a cleansing enema. An enema is contraindicated as it may worsen abdominal inflammation or cause perforation.
E. Prepare child and parents for ostomy placement. While surgery may be needed, an ostomy is not always required for appendicitis.
F. Educate child and parents about plan of care. Providing education helps reduce anxiety and ensures understanding of the interventions.
G. Administer an analgesic. Pain management is essential for comfort and reduces physiologic stress.
H. Administer antibiotics. Antibiotics are started preoperatively to manage infection or prevent complications if perforation is suspected.

A. "I will set the temperature of the hot water heater to 140 degrees." B. "I will turn pot handles towards the front of the stove when cooking." C. "I don't need to apply sunscreen to my child if he is outside after 3 p.m." D. “I will plug protective guards into my electrical outlets."

Correct Answer is D

Explanation

A. "I will set the temperature of the hot water heater to 140 degrees." The hot water heater should be set to 120°F (49°C) or lower to prevent scald injuries. A setting of 140°F significantly increases the risk of burns.
B. "I will turn pot handles towards the front of the stove when cooking." Pot handles should be turned toward the back of the stove to prevent a child from grabbing or knocking them over.
C. "I don't need to apply sunscreen to my child if he is outside after 3 p.m." Sunscreen is essential any time a child is outdoors during daylight, regardless of the time, to protect against harmful UV rays.
D. "I will plug protective guards into my electrical outlets." Installing protective guards helps prevent electrical burns by stopping toddlers from inserting objects into outlets.

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A nurse is assessing a 4-year-old child who is 2 days postoperative following insertion of a ventriculoperitoneal shunt. Which of the following findings is the nurse's priority?

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Naxlex Comprehensive Predictor Exams

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Explanation

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