A nurse is caring for an infant.
Which of the following actions should the nurse take?
Evaluate for the presence of a Babinski reflex.
Measure the head circumference.
Assess the pupillary reaction to light.
Encourage parents to feed the infant.
Palpate fontanel level.
Correct Answer : A,B,C,E
Choice A: Evaluate for the presence of a Babinski reflex
The Babinski reflex, also known as the plantar reflex, is a normal reflex in infants up to 2 years old. When the sole of the foot is stroked, the big toe moves upward, and the other toes fan out. This reflex helps assess the neurological function and integrity of the corticospinal tract. In the context of a subdural hematoma, evaluating the Babinski reflex can help determine if there is any neurological impairment or increased intracranial pressure, which could indicate worsening of the condition.
Choice B: Measure the head circumference
Measuring the head circumference is crucial in infants, especially those with head injuries, as it helps monitor brain growth and detect any abnormal swelling or increased intracranial pressure. An increase in head circumference can indicate the presence of intracranial bleeding or edema, which requires immediate medical attention. Regular monitoring of head circumference allows healthcare providers to track the infant’s neurological development and identify any deviations from the normal growth curve.
Choice C: Assess the pupillary reaction to light
Assessing the pupillary reaction to light is an essential neurological assessment in infants with head injuries. The pupils’ response to light provides information about the function of the optic nerve and the brainstem. A normal pupillary reaction indicates that the brainstem is functioning correctly, while an abnormal reaction can suggest increased intracranial pressure or brain injury. In this case, the nurse should assess the pupillary reaction to ensure there are no signs of neurological deterioration.
Choice D: Encourage parents to feed the infant
Encouraging parents to feed the infant is not recommended in this scenario. The infant’s inability to awaken for feeding and sleeping through the vital sign assessment could indicate a decreased level of consciousness or neurological impairment. Feeding an infant in such a state could increase the risk of aspiration and further complications. Instead, the nurse should focus on monitoring the infant’s neurological status and ensuring their safety.
Choice E: Palpate fontanel level
Palpating the fontanel level is an important assessment in infants with head injuries. The fontanels, or soft spots on the infant’s skull, provide valuable information about intracranial pressure. A bulging fontanel can indicate increased intracranial pressure, while a sunken fontanel may suggest dehydration. In this case, the nurse should palpate the fontanel to assess for any abnormalities that could indicate changes in the infant’s condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Turn the client every 4 hours: Regularly turning the client can help prevent pressure ulcers and improve overall circulation, but it is not the most effective measure specifically for preventing ventilator-associated pneumonia (VAP). While repositioning can help with lung expansion and secretion clearance, oral care is more directly related to reducing VAP risk.
Choice B reason:
Brush the client’s teeth with a suction toothbrush every 12 hours: Oral care is crucial in preventing VAP. Bacteria from the mouth can easily travel to the lungs, especially in intubated patients. Using a suction toothbrush helps remove dental plaque and secretions, reducing the bacterial load and the risk of infection. This practice is a key component of VAP prevention bundles.
Choice C reason:
Provide humidity by maintaining moisture within the ventilator tubing: While maintaining humidity is important to prevent drying of the respiratory mucosa and to help with secretion clearance, it does not directly reduce the risk of VAP. Proper humidification is necessary for patient comfort and respiratory function but is not a primary VAP prevention strategy.
Choice D reason:
Position the head of the client’s bed in the flat position: Positioning the head of the bed flat can increase the risk of aspiration, which is a significant risk factor for VAP. The head of the bed should be elevated to 30-45 degrees to reduce the risk of aspiration and promote better lung expansion.
Correct Answer is C
Explanation
Choice A: Apply Bilateral Wrist Restraints
Applying bilateral wrist restraints can be necessary in some cases to prevent the child from touching or interfering with the surgical site. However, restraints should be used as a last resort and only when absolutely necessary. They can cause distress and discomfort to the child and should be monitored closely to prevent any complications.
Choice B: Administer Opioids for Pain
Administering opioids for pain management is a common practice post-surgery to ensure the child is comfortable. However, opioids should be used cautiously due to the risk of side effects and potential for dependency. Non-opioid pain management strategies, such as acetaminophen or ibuprofen, are often preferred unless the pain is severe.
Choice C: Implement a Soft Diet
Implementing a soft diet is crucial for a child who is 24 hours postoperative following a cleft palate repair. The surgical site in the mouth is still healing, and a soft diet helps prevent any damage or irritation to the area. Soft foods are easier to swallow and less likely to cause pain or disrupt the healing process. Examples of soft foods include mashed potatoes, yogurt, and pureed fruits.
Choice D: Offer Fluids Through a Straw
Offering fluids through a straw is not recommended for a child who has undergone cleft palate repair. The suction created by using a straw can put pressure on the surgical site and potentially cause complications. Instead, fluids should be offered using a cup or a spoon to minimize any risk to the healing palate.
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