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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A highly pruritic profuse macule to papule rash on the trunk.
Explanation: This description does not align with the typical presentation of erythema infectiosum. The rash in fifth disease is not highly pruritic, and the initial characteristic is the "slapped face" appearance.
B. A discrete pinkish red maculopapular rash that is spreading to the trunk.
Explanation: While erythema infectiosum can involve a discrete rose-pink maculopapular rash on the trunk and limbs, the key initial characteristic is the "slapped face" appearance.
C. An erythema on the face that has a "slapped face appearance."
Explanation:
Erythema infectiosum, caused by the parvovirus B19, is commonly known as fifth disease. The initial rash often presents with a distinctive "slapped face" appearance, characterized by erythema (redness) on the cheeks, resembling a slapped appearance. Subsequently, a discrete rose-pink maculopapular rash may develop on the trunk and limbs.
D. A discrete rose-pink maculopapular rash on the trunk.
Explanation: This description aligns with the later stages of the rash in erythema infectiosum. However, the initial characteristic is the "slapped face" appearance on the face.
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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