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","C","F"]
Explanation
A. Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling.
Explanation: Elevating the extremity can help reduce swelling, especially in the initial period after casting.
B. Place a heating pad on the lower end of the cast and over the fingers if the fingers feel cold.
Explanation: Applying heat can increase the risk of burns and is not recommended. If the fingers feel cold, it may indicate a circulation issue, and the healthcare provider should be contacted.
C. Keep small toys and sharp objects away from the cast.
Explanation: Keeping small toys and sharp objects away from the cast is important to prevent injury or damage to the cast.
D. Use a padded ruler or another padded object to scratch the skin under the cast if it itches.
Explanation: Inserting objects under the cast can lead to complications, including skin damage or infection. It is advisable not to insert anything into the cast.
E. Use the fingertips to lift the cast while it is drying.
Explanation: Lifting or manipulating the cast during the drying process can compromise its integrity and should be avoided. The cast needs to dry completely to provide proper support and immobilization.
F. Contact the primary health care provider (PHCP) if the child complains of numbness or tingling in the extremity.
Explanation: Numbness or tingling can indicate a circulation problem, and it is important to contact the healthcare provider for further assessment.
Correct Answer is ["C","D","E"]
Explanation
A. Set the water heater at 65.6° C (150° F):
The recommended temperature for a water heater is around 49°C (120°F) to prevent burns. Setting it at 65.6°C (150°F) can lead to scald injuries.
B. Install accordion style gates: Accordion-style gates are not recommended because they can pose a strangulation risk. The safer option is to use gates with vertical or horizontal slats that are spaced closer together.
C. Fit the mattress so that it is snug against the sides of the crib: A snug-fitting mattress prevents gaps where the baby could get trapped or injured.
D. Tie plastic bags in knots before discarding them:
This prevents accidental suffocation or choking hazards that can occur if an infant gets hold of a plastic bag.
E. Serve food in small, non-circular pieces:Serving food in small, non-circular pieces reduces the risk of choking. Infants should be given age-appropriate foods to minimize the risk of choking, and cutting food into small, easy-to-manage pieces is recommended.
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