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. Edema in the lower extremities:
Incorrect: Edema in the lower extremities is more characteristic of right-sided heart failure. In left-sided failure, pulmonary congestion is more prominent.
B. Ascites:
Incorrect: Ascites, or fluid accumulation in the abdominal cavity, is also more commonly associated with right-sided heart failure.
C. Shortness of breath:
Correct Answer: Left-sided congestive heart failure can lead to pulmonary congestion, resulting in difficulty breathing or shortness of breath. This is often observed as increased work of breathing, rapid breathing, or other signs of respiratory distress in infants.
D. Hepatomegaly:
Incorrect: Hepatomegaly, or enlargement of the liver, is another manifestation more commonly associated with right-sided heart failure.
Correct Answer is D
Explanation
A. Diarrhea
Explanation: Diarrhea is not a typical sign of Hirschsprung's disease. Instead, the condition is associated with constipation due to the obstructed passage of stool.
B. Regurgitation of feedings
Explanation: Regurgitation of feedings is not a characteristic sign of Hirschsprung's disease. It may be seen in other gastrointestinal conditions, but not specifically in this disorder.
C. Projectile vomiting
Explanation: Projectile vomiting is not a typical sign of Hirschsprung's disease. It may be associated with conditions such as pyloric stenosis, but it is not a characteristic feature of Hirschsprung's disease.
D. Foul-smelling ribbon-like stools
Explanation:
Hirschsprung's disease is a congenital condition characterized by the absence of ganglion cells in the rectum and a portion of the colon. The lack of ganglion cells results in functional obstruction, causing stool to accumulate in the affected area. One of the hallmark signs is the presence of foul-smelling, ribbon-like stools, often described as "fecal pellets" or "pellets" due to the obstructed passage of stool.
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