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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Orthopnea
Explanation:
Orthopnea refers to difficulty breathing that occurs when lying flat. In heart failure, fluid may accumulate in the lungs, leading to respiratory distress when the child is in a supine position. Orthopnea is a common symptom of heart failure in both adults and children.
B. Bradycardia
Explanation: Bradycardia (slow heart rate) is not a typical finding in heart failure. Heart failure often leads to compensatory mechanisms, including an increased heart rate (tachycardia), to maintain cardiac output.
C. Weight loss
Explanation: Weight loss is not a typical finding in heart failure. In fact, heart failure in children may lead to fluid retention and weight gain rather than weight loss.
D. Increased urine output
Explanation: Heart failure in toddlers is more likely to be associated with decreased urine output rather than increased urine output. Reduced cardiac output can result in decreased blood flow to the kidneys, leading to decreased urine production and potential fluid retention. Increased urine output is not a characteristic finding in heart failure.

Correct Answer is B
Explanation
A. Changes in the voice signal the beginning of puberty.
Explanation: Changes in the voice, specifically deepening, are associated with puberty, but they typically occur later in puberty. The voice change is related to the growth of the larynx (Adam's apple) and tends to happen after other physical changes.
B. Gynecomastia commonly occurs during late puberty.
Explanation:
Gynecomastia, the development of breast tissue in males, is a common occurrence during puberty. It is often temporary and tends to happen during late puberty. The enlargement of breast tissue can be a source of concern for adolescent boys, and providing information about the normalcy and temporary nature of gynecomastia can be reassuring for both parents and boys.
C. Puberty might be delayed if scrotal changes have not occurred by the age of 11 years.
Explanation: The timing of pubertal changes can vary among individuals. While certain age ranges are provided as general guidelines, the absence of scrotal changes by a specific age does not necessarily indicate delayed puberty. Puberty is a gradual process with individual variations.
D. Growth spurts in height occur toward the end of midpuberty.
Explanation: Growth spurts in height, known as the adolescent growth spurt, typically occur during midpuberty. This phase is marked by rapid growth in height, changes in body composition, and the development of secondary sexual characteristics.
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