A nurse is conducting a postoperative assessment on an infant who has just had a ventriculoperitoneal shunt placed for hydrocephalus. Which assessment finding would indicate a malfunction in the shunt?
Movement of all extremities.
Negative Brudzinski sign.
Incisional pain.
Bulging fontanel.
The Correct Answer is D
Choice A reason: Movement of all extremities is expected and does not indicate a shunt malfunction.
Choice B reason: A negative Brudzinski sign is a normal finding and does not suggest a shunt malfunction.
Choice C reason: While incisional pain is common after surgery, it is not a specific indicator of shunt malfunction.
Choice D reason: This is the correct choice. A bulging fontanel can indicate increased intracranial pressure, which may suggest a shunt malfunction.
 
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Keeping suction equipment at bedside is important to maintain airway patency and prevent aspiration.
Choice B reason: Positioning the child upright for feedings can help prevent aspiration and is a recommended practice.
Choice C reason: Feeding slowly using specialized feeding bottles can help the infant feed effectively and safely.
Choice D reason: This is the correct choice. Breastfeeding is often possible with the use of special techniques and should not be discouraged unless specifically contraindicated.
Correct Answer is D
Explanation
Choice A reason: Administering a bolus of D10W is not the first-line treatment for severe dehydration and may not address the immediate fluid needs of the infant.
Choice B reason: Offering an oral rehydration solution is not appropriate for an infant with severe dehydration and a compromised ability to hold down fluids.
Choice C reason: Administering a bolus of hypertonic saline is not typically the initial treatment for dehydration and could potentially worsen the infant's condition.
Choice D reason: This is the correct choice. Administering a bolus of normal saline is the immediate action to treat severe dehydration and restore circulatory volume.
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