A nurse is assessing an infant who has hydrocephalus. Which of the following clinical manifestations should the nurse expect?

Depressed scalp veins

Sunken anterior fontanels

Bulging eyes

Separated cranial sutures

Answer and Explanation

The Correct Answer is D

A. Depressed scalp veins: This is an incorrect choice. In hydrocephalus, there is increased pressure within the skull due to the accumulation of cerebrospinal fluid (CSF). This increased pressure typically leads to distended scalp veins rather than depressed ones.

B. Sunken anterior fontanels: This is an incorrect choice. The fontanel, also known as the soft spot on an infant's head, may actually bulge rather than appear sunken in cases of hydrocephalus due to increased intracranial pressure.

C. Bulging eyes: In individuals with hydrocephalus, especially infants and young children, bulging eyes can sometimes occur. The increased pressure inside the skull can affect various structures within the brain, including the optic nerve and the muscles that control eye movement. This can lead to a condition called papilledema, where the optic nerve becomes swollen due to the pressure. Papilledema can cause changes in vision and, in some cases, contribute to the appearance of bulging eyes.

D. Separated cranial sutures: The separation of cranial sutures in hydrocephalus occurs due to the increased pressure from the excess CSF. This pressure can cause the bones of the skull to move apart, leading to visible gaps or widening of the sutures. Clinically, this can be observed through imaging studies such as CT scans or MRI.

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Correct Answer is D

Explanation

A. An adolescent who has iron-deficiency anemia and an Hgb level of 11 g/dL (10 to 15.5 g/dL):

An Hgb level of 11 g/dL in an adolescent with iron-deficiency anemia is within the expected range for someone with this condition. While iron-deficiency anemia requires management, it is not an urgent or critical condition requiring immediate intervention.

B. A school-age child who has diabetes mellitus and an HbA1c of 8% (less than 7%):

An HbA1c level of 8% in a child with diabetes mellitus indicates poor glycemic control and may increase the risk of long-term complications. While it requires attention and adjustment of the treatment plan, it is not an urgent or critical condition requiring immediate intervention.

C. A toddler who has moderate dehydration and an RBC count of 5.6/mm3 (4 to 5.5/mm3):

Moderate dehydration in a toddler is a concerning finding that requires prompt intervention to restore fluid balance and prevent complications. However, the RBC count of 5.6/mm3 is within the normal range and does not indicate an urgent or critical condition.

D. A preschooler who has cystic fibrosis-related diabetes and a WBC count of 15,000/mm3 (5,000 to 10,000/mm3):

A WBC count of 15,000/mm3 in a preschooler with cystic fibrosis-related diabetes may indicate an infection or inflammatory process. Elevated WBC count warrants further assessment and possible intervention to identify and treat the underlying cause, making this the priority.

A. "You should give your child aspirin if they report pain at the site." B. "You can remove the pressure dressing 8 hours after the procedure." C. "Your child can soak in the bathtub 24 hours after the procedure." D. "Your child should avoid strenuous physical activities for several days."

Correct Answer is D

Explanation

A. "You should give your child aspirin if they report pain at the site."

This statement is incorrect. Aspirin is a blood-thinning medication that can increase the risk of bleeding, which is particularly concerning after a cardiac catheterization procedure. It is not recommended to administer aspirin unless specifically instructed by the healthcare provider.

B. "You can remove the pressure dressing 8 hours after the procedure."

This statement is incorrect. The pressure dressing applied after a cardiac catheterization procedure is typically left in place for a specific period of time, as determined by the healthcare provider. The dressing helps prevent bleeding at the insertion site. It is essential to follow the healthcare provider's instructions regarding the timing of dressing removal.

C. "Your child can soak in the bathtub 24 hours after the procedure."

This statement is incorrect. Immersing the insertion site in water, such as soaking in a bathtub, should be avoided for a certain period after a cardiac catheterization procedure to reduce the risk of infection. The healthcare provider will provide specific instructions on when it is safe for the child to bathe or shower.

D. "Your child should avoid strenuous physical activities for several days."

This statement is correct. After a cardiac catheterization procedure, it is typically recommended to avoid strenuous physical activities for a specified period to allow the insertion site to heal properly and reduce the risk of complications such as bleeding or hematoma formation.

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