A nurse is collecting data from an infant who has hydrocephalus.
Which of the following findings should the nurse expect?
Soft and flat fontanels.
Proteinuria.
Dilated scalp veins.
Hypertension.
The Correct Answer is A
Choice A rationale
A bulging fontanel is a common sign of hydrocephalus in infants. The fontanels, or soft spots on an infant’s head, allow for brain growth. When there is an excess of cerebrospinal fluid, as in hydrocephalus, it can cause the fontanels to bulge outwards.
Choice B rationale
Proteinuria, or excess protein in the urine, is not typically associated with hydrocephalus. It is more commonly seen in kidney diseases.
Choice C rationale
Dilated scalp veins may be seen in hydrocephalus due to increased pressure, but it is not as common or as early a sign as a bulging fontanel.
Choice D rationale
Hypertension is not typically associated with hydrocephalus in infants. While hydrocephalus can cause increased intracranial pressure, it does not typically cause systemic hypertension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
The carotid pulse is not the most reliable location to check an infant’s pulse because it can be difficult to locate and can cause discomfort to the infant.
Choice B rationale
The dorsalis pedis pulse is not the most reliable location to check an infant’s pulse because it can be difficult to locate in small infants.
Choice C rationale
The temporal pulse is not the most reliable location to check an infant’s pulse because it can be affected by external factors such as temperature and can be difficult to locate in small infants.
Choice D rationale
The apical pulse is the most reliable location to check an infant’s pulse. It is located at the apex of the heart and can be easily heard using a stethoscope. It provides the most accurate assessment of the heart rate.
Correct Answer is D
Explanation
Choice A rationale
While the genitourinary system can be affected in individuals with Down syndrome, it is not the most commonly affected body system. Down syndrome is a genetic condition where a person is born with an extra chromosome. This can affect how their brain and body develop, leading to both physical and mental challenges.
Choice B rationale
The reproductive system is not the most commonly affected body system in individuals with Down syndrome. While individuals with Down syndrome can have reproductive health issues, these are not as common as issues with other body systems.
Choice C rationale
The gastrointestinal system can be affected in individuals with Down syndrome, but it is not the most commonly affected body system. Some individuals with Down syndrome may experience gastrointestinal issues such as constipation or gastroesophageal reflux disease.
Choice D rationale
The cardiovascular system is the most commonly affected body system in individuals with Down syndrome. Almost half of babies with Down syndrome have congenital heart disease (CHD), the most common type of congenital anomaly. CHD can lead to high blood pressure in the lungs, an inability of the heart to effectively and efficiently pump blood, and cyanosis (blue-tinted skin caused by reduced oxygen in the blood)3.
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