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","E"]
Explanation
A. "The manifestations are lessened by taking the prednisone every other day instead of daily."
Correct Answer: Cushingoid characteristics can be associated with long-term corticosteroid use. Taking prednisone every other day, rather than daily, can help minimize these manifestations while still providing the needed therapeutic effect.
B. "You need to be sure to talk to the doctor about the Cushingoid characteristics."
Incorrect: While it is important for the parents to communicate with the doctor, this statement is less therapeutic than option 3, which opens up a more collaborative and supportive conversation.
C. "Which manifestations of this condition do you find most troublesome?"
Correct Answer: This open-ended question allows the parents to express their concerns and frustrations. It facilitates communication between the parents and healthcare provider to address specific issues they find most troublesome.
D. "I am sure it will be all right; they hardly look unusual."
Incorrect: Downplaying the parents' concerns may not be the most therapeutic approach. Acknowledging their concerns and providing information about the reversible nature of cushingoid characteristics would be more helpful.
E. "The cushingoid appearance will gradually disappear once the corticosteroids are tapered and discontinued."
Correct Answer: Cushingoid characteristics are reversible, and they tend to improve as the dose of corticosteroids is tapered and eventually discontinued.
Correct Answer is ["B","C","E"]
Explanation
A. Stopping the medication when the child feels better: Antibiotics should be taken for the full prescribed course, even if the child starts feeling better. Stopping prematurely can lead to incomplete eradication of the infection and potential antibiotic resistance.
B. Written information about the medication: Providing written information about the medication helps reinforce verbal instructions and serves as a reference for the parents or caregivers.
C. The reason why the child is taking the medication: It is essential to explain to parents or caregivers the purpose of the medication, such as treating a specific infection. Understanding the reason for the medication promotes compliance.
D. Using a kitchen spoon to administer the medication: Using a kitchen spoon can result in inaccurate dosing. The nurse should recommend using an appropriate measuring device, such as a calibrated oral syringe or a dosing spoon, to ensure accurate dosage administration.
E. The adverse effects of the medication: Educating parents or caregivers about potential adverse effects helps them monitor for any signs of complications and seek medical attention if needed.
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