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. Rye toast
Explanation: Rye contains gluten, so it is not appropriate for individuals with celiac disease. Rye, like wheat and barley, should be avoided.
B. Rice
Explanation:
Celiac disease is a condition characterized by an immune reaction to gluten, a protein found in wheat, barley, and rye. Therefore, individuals with celiac disease need to avoid gluten-containing foods. Rice is naturally gluten-free, making it a suitable and safe option for individuals with celiac disease.
C. Wheat bread
Explanation: Wheat contains gluten, and products made from wheat, including wheat bread, should be strictly avoided by individuals with celiac disease.
D. Oatmeal
Explanation: Oats themselves are gluten-free, but they are often contaminated with gluten during processing. Some individuals with celiac disease can tolerate pure, uncontaminated oats, while others may need to avoid oats altogether. It is important to choose certified gluten-free oats if including them in the diet.
Correct Answer is B
Explanation
A. Use a padded tongue blade:
Incorrect: Inserting anything into the child's mouth, including a padded tongue blade, is not recommended during a seizure. It can lead to oral and airway injuries. It's important to keep the airway clear, but this is achieved by positioning the child laterally.
B. Position the child laterally.
Correct Answer: This is the correct action. Placing the child on their side helps prevent aspiration of fluids and promotes a clear airway during the seizure. It also reduces the risk of injury.
C. Restrain the child's arms:
Incorrect: Restraining the child's arms can increase the risk of injury and is not recommended during a seizure. It's crucial to ensure a safe environment and prevent injury, but physically restraining the child is not the appropriate approach.
D. Attempt to stop the seizure:
Incorrect: It is not within the nurse's capacity to immediately stop a seizure. Seizures are neurological events, and they need to run their course. The focus should be on ensuring the safety of the child during the seizure.
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