A nurse is planning care for a child who has increased intracranial pressure with a decrease in the level of consciousness. Which of the following interventions should the nurse include inthe plan of care?
Perform active range-of-motion exercises.
Maintain the head at a midline position.
Suction the airway frequently.
Perform neurological checks every 4 hours.
The Correct Answer is B
A. Active range-of-motion exercises are not appropriate for a child with increased intracranial pressure and decreased level of consciousness, as they may increase intracranial pressure.
B. Maintaining the head at a midline position helps promote proper cerebral perfusion and reduces the risk of further increases in intracranial pressure.
C. Frequent suctioning of the airway can stimulate the gag reflex and increase intracranial pressure. Suctioning should only be done as needed to maintain a clear airway.
D. Neurological checks should be performed more frequently than every 4 hours in a child with increased intracranial pressure and decreased level of consciousness, ideally at least every hour or as indicated by the child's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A fundal height of 2 fingerbreadths below the umbilicus in a client who is 2 days postpartum is within the expected range for that time frame and does not require immediate assessment.
B. A client who is 1 day postpartum and has not voided in 8 hours may be at risk for urinary retention, which can lead to complications such as bladder distension or urinary tract infection. Prompt assessment and intervention are needed.
C. Not having a bowel movement since prior to admission is not an urgent concern in the
immediate postpartum period, especially if the client is otherwise stable and not experiencing discomfort or other symptoms.
D. Lochia serosa, which is the normal vaginal discharge that occurs 3 to 10 days postpartum, is not an urgent concern and does not require immediate assessment.
Correct Answer is B
Explanation
A. "I should place a rolled blanket along each side of my baby's head in the car seat." - Incorrect. Placing rolled blankets on each side of the baby's head is not recommended as it can increase the risk of suffocation. Infants should be positioned in the car seat without any extra padding or blankets.
B. "I should place my baby's car seat rear-facing until 6 months of age." - Correct. Rear- facing car seats are recommended for infants until they reach at least 2 years of age or until they outgrow the weight and height limits specified by the car seat manufacturer. This position provides the best protection for the baby's head, neck, and spine in the event of a crash.
C. "I should put the car seat retainer clip at the level of my baby's belly button." - Incorrect. The retainer clip should be positioned at armpit level to secure the harness straps properly.
D. "I should position my baby's car seat at a 90-degree angle in the car." - Incorrect. Car seats should be installed at the appropriate recline angle according to the manufacturer's instructions, which may vary depending on the specific car seat model and the child's age and size.
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