An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period?

Test the urine for protein

Reposition the infant frequently.

Assess blood pressure every 15 minutes

Provide a stimulating environment

Answer and Explanation

The Correct Answer is B

A. Test the urine for protein.
Explanation: Testing urine for protein is not a priority nursing intervention in the preoperative period for an infant with hydrocephalus. The focus is on preventing complications related to immobility and positioning.
B. Reposition the infant frequently.
Explanation:
Repositioning the infant frequently is a crucial intervention to prevent complications such as pressure ulcers (bedsores). Infants with hydrocephalus may be at an increased risk of skin breakdown due to prolonged immobility and pressure on specific areas. Repositioning helps distribute pressure, improves circulation, and reduces the risk of skin breakdown.
C. Assess blood pressure every 15 minutes.
Explanation: While monitoring blood pressure is important in certain situations, it is not typically the priority for an infant with hydrocephalus in the preoperative period. The focus is on preventing skin breakdown through repositioning.
D. Provide a stimulating environment.
Explanation: While providing a stimulating environment can be beneficial for infant development, it is not the priority in the preoperative period for an infant with hydrocephalus. The primary concern is addressing potential complications related to immobility, such as skin breakdown.

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Correct Answer is A

Explanation

A. "This test will confirm if your child had a recent streptococcal infection."
Explanation:
The anti-streptolysin O (ASO) titer is a blood test used to detect the presence of antibodies against streptolysin O, a toxin produced by group A Streptococcus bacteria. A rise in ASO titers indicates a recent streptococcal infection. It does not confirm rheumatic fever directly but helps in identifying a recent streptococcal infection, which is a predisposing factor for rheumatic fever.
B. "This test will indicate if your child has rheumatic fever."
Explanation: While a positive ASO titer may suggest a recent streptococcal infection, it does not directly indicate rheumatic fever. The diagnosis of rheumatic fever involves a combination of clinical criteria, including evidence of a recent streptococcal infection, along with specific signs and symptoms.
C. "This test will confirm if your child has immunity to streptococcal bacteria."
Explanation: The ASO titer does not measure immunity to streptococcal bacteria. It specifically detects antibodies produced in response to a recent streptococcal infection.
D. "This test will indicate if your child has a therapeutic blood level of an aminoglycoside."
Explanation: The ASO titer is not used to monitor therapeutic blood levels of aminoglycosides. It is specific to detecting antibodies related to streptococcal infections and is not related to aminoglycoside therapy.

A. An infectious disease of the central nervous system B. An inflammation of the brain as a result of a viral illness C. A chronic disability characterized by impaired muscle movement and posture D. A congenital condition that results in moderate to severe intellectual disabilities

Correct Answer is C

Explanation

A. An infectious disease of the central nervous system
Explanation: Cerebral palsy is not caused by an infectious disease of the central nervous system. It is a non-progressive neurological disorder that arises from brain damage, often during prenatal development.
B. An inflammation of the brain as a result of a viral illness
Explanation: While inflammation of the brain due to a viral illness can lead to neurological complications, cerebral palsy is not specifically caused by inflammation resulting from a viral illness.
C. A chronic disability characterized by impaired muscle movement and posture
Explanation:
Cerebral palsy is a chronic condition that primarily affects motor function and posture. It results from damage to the developing brain, often occurring before or during birth. The impaired muscle movement and posture associated with cerebral palsy can lead to limitations in activities of daily living and mobility.
D. A congenital condition that results in moderate to severe intellectual disabilities
Explanation: Cerebral palsy primarily affects motor function, and intellectual disabilities are not an inherent component of cerebral palsy. While some individuals with cerebral palsy may have associated cognitive impairments, it is not a defining characteristic of the disorder.

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An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who was admitted with suspected rheumatic fever. The provider prescribes an anti-streptolysin O (ASO) titer. The parent asks the nurse the purpose of the test. Which of the following responses should the nurse make?

Correct Answer is A

Explanation

The parents of a child recently diagnosed with cerebral palsy ask the nurse about the limitations of the disorder. The nurse responds by explaining that the limitations occur as a result of which pathophysiological process?

Correct Answer is C

Explanation

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