A nurse is assessing an infant who has hydrocephalus and is 6 hr postoperative following placement of a ventriculoperitoneal (VP) shunt. Which of the following findings should the nurse report to the provider?

Irritability when being held

Heart rate 122/min

Hypoactive bowel sounds

Urine specific gravity 1.018

Answer and Explanation

The Correct Answer is A

A. Irritability when being held may indicate increased intracranial pressure or complications related to the VP shunt placement and should be reported to the provider.

B. A heart rate of 122/min is within the normal range for an infant and does not require reporting.

C. Hypoactive bowel sounds may occur postoperatively, especially if the infant has not been fed or has been under anesthesia, and is not an immediate concern.

D. A urine specific gravity of 1.018 is within normal limits for infants and does not indicate a need for reporting.

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Correct Answer is A

Explanation

A. Assisting with deep breathing and coughing is the priority action. This is crucial in preventing respiratory complications, such as atelectasis or pneumonia, especially following abdominal surgery. Deep breathing exercises can help expand the lungs and promote ventilation.

B. Monitoring the incision site for signs of infection is important, but it is not the immediate priority. The client’s respiratory function takes precedence in the early postoperative period.

C. Assessing fluid intake is important for overall recovery, but it is not as critical as ensuring the client can breathe effectively and prevent complications.

D. While ambulation is beneficial for recovery and preventing complications such as deep vein thrombosis, the nurse must first ensure the client can manage their airway and breathing.

A. Dietary salt restriction B. Absence of symptoms C. Addition of a new medication D. A detailed plan of care

Correct Answer is D

Explanation

A. Dietary salt restriction is challenging but is a specific intervention that can be managed with education and support.

B. The absence of symptoms can significantly hinder compliance because clients may not perceive the need to adhere to a treatment plan if they do not feel unwell. This perception can lead to underestimating the importance of managing their blood pressure.

C. The addition of a new medication may pose some challenges, but clients often adapt to new medications with proper guidance.

D. A detailed plan of care can enhance understanding and compliance, making it less likely to be a barrier compared to the lack of symptomatic cues indicating a need for treatment.

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A nurse is assessing an infant who has hydrocephalus and is 6 hr postoperative following placement of a ventriculoperitoneal (VP) shunt. Which of the following findings should the nurse report to the provider?

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