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 B

Explanation

A. A child who is postoperative following a tonsillectomy and reports moderate throat pain.

While postoperative pain management is important, moderate throat pain in a child who has undergone a tonsillectomy is expected. This client's condition is stable, and their pain can be managed with appropriate interventions. It is not the most urgent situation among the options provided.

B. A child who had a cardiac catheterization using the femoral artery and has blanching of the toes.

Blanching of the toes following a cardiac catheterization using the femoral artery can indicate compromised circulation, potentially leading to ischemia or necrosis. This requires immediate assessment to prevent further complications.

C. A child who has bacterial pneumonia and is due for their initial dose of IV antibiotics.

While timely administration of antibiotics is important in the treatment of bacterial pneumonia, missing the initial dose by a short period of time is not likely to result in significant harm compared to a potential circulatory compromise in option B.

D. A child who has juvenile idiopathic arthritis and needs assistance with the application of prescribed splints.

While providing assistance with splint application is necessary for comfort and mobility, it is not as urgent as assessing potential circulatory compromise or initiating antibiotic therapy for pneumonia.

A. Temperature of 38° C (100.4° F) B. Family history of sudden unexpected infant death (SUID) C. Taking an antihistamine for seasonal allergies D. Receiving prednisone for nephrotic syndrome

Correct Answer is D

Explanation

A. Temperature of 38°C (100.4°F):A mild fever is not a contraindication for the MMR vaccine. In fact, a low-grade fever is common after immunizations and does not warrant withholding the vaccine.

B. Family history of sudden unexpected infant death (SUID): While a family history of SUID may be concerning, it is not a contraindication for administering the MMR vaccine. This history would not directly impact the safety or effectiveness of the vaccine.

C. Taking an antihistamine for seasonal allergies: Taking an antihistamine for seasonal allergies does not typically contraindicate the administration of the MMR vaccine. Antihistamines are generally safe to use with vaccines, and they do not interfere with the immune response to the vaccine.

D. Receiving prednisone for nephrotic syndrome:Prednisone is an immunosuppressive medication. Children receiving high-dose corticosteroids (such as prednisone) should avoid live vaccines like MMR

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

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