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.
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Related Questions
Correct Answer is B
Explanation
A. Cranberry juice
Explanation: Acidic and citrus juices, including cranberry and orange juice, should be avoided in the immediate postoperative period as they can be irritating to the surgical site and may increase the risk of bleeding.
B. Crushed ice
Explanation:
After a tonsillectomy, it's important to provide cold and clear fluids to soothe the throat and prevent bleeding. Crushed ice is a suitable option as it helps keep the throat cool and provides hydration without irritating the surgical site. Cold liquids can help minimize swelling and provide comfort.
C. Vanilla milkshake
Explanation: While milkshakes may be appealing, dairy products can coat the throat and may not be recommended immediately after surgery. Additionally, it's crucial to avoid using straws, as sucking can increase the risk of bleeding.
D. Orange juice
Explanation: As mentioned earlier, citrus juices like orange juice can be irritating to the surgical site and are not recommended in the early postoperative period after a tonsillectomy. It's essential to choose clear and non-acidic fluids to support healing and prevent complications.
Correct Answer is C
Explanation
A. Ribbon-like stools
Explanation: Ribbon-like or pencil-thin stools are associated with conditions affecting the rectum, such as colorectal cancer, but they are not a typical sign of intussusception.
B. Profuse projectile vomiting
Explanation: Profuse projectile vomiting is not a typical sign of intussusception. Vomiting may occur, but it is not the primary characteristic feature.
C. Bright red blood and mucus in the stools
Explanation:
Intussusception is a condition in which one part of the intestine slides into another, causing a blockage. One of the classic signs of intussusception is the presence of "currant jelly" stools, which are characterized by a mixture of bright red blood and mucus in the stools. This occurs due to the compression of the blood vessels in the intestine, leading to bleeding and mucosal discharge.
D. Watery diarrhea
Explanation: Watery diarrhea is not a typical sign of intussusception. The condition is more commonly associated with abdominal pain, vomiting, and the characteristic "currant jelly" stools.
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