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 ["A","B","D"]
Explanation
A. Varicella (VARI): Correct
Explanation: The varicella vaccine protects against chickenpox. The CDC recommends that children receive the first dose of the varicella vaccine at age 1.
B. Diphtheria, tetanus, and acellular pertussis (DTaP): Correct
Explanation: The DTaP vaccine protects against diphtheria, tetanus, and pertussis. The first dose is typically given at 2 months, with subsequent doses given at 4 months, 6 months, 15-18 months, and 4-6 years of age.
C. Human papillomavirus (HPV4): Incorrect
Explanation: The HPV vaccine is not typically administered at age 1. It is usually recommended for adolescents, starting around age 11 or 12. The HPV vaccine is given in a series of doses.
D. Measles, mumps, rubella (MMR): Correct
Explanation: The MMR vaccine protects against measles, mumps, and rubella. The first dose is usually given at age 1, with a second dose recommended at 4-6 years of age.
E. Rotavirus (RV): Incorrect
The rotavirus vaccine is usually given in a series of doses starting at 2 months of age, with the last dose administered by 8 months. It is not a vaccine that is typically given at age 1.
Correct Answer is ["A","D","F"]
Explanation
A.Move furniture away from the child.
Explanation: Creating a safe environment is important during a seizure. Moving furniture away from the child helps prevent injury.
B.Place the child in a prone position.
Explanation: Placing the child in a prone position (face down) is not recommended. The child should be placed on their side to allow for drainage of oral secretions and to prevent aspiration.
C. Restrain the child.
Explanation: Restraint is generally not recommended during a seizure, as it may cause injury to the child or the person providing care. Allow the seizure to run its course, and focus on keeping the environment safe.
D.Time the seizure.
Explanation: Timing the duration of the seizure is important for medical evaluation and management. Note the start and end times of the seizure.
E. Insert a padded tongue blade in the child's mouth.
Explanation: Inserting any object, including a padded tongue blade, into the child's mouth during a seizure is not recommended. This can lead to oral and dental injuries. Maintaining a clear airway and protecting the child from injury are priorities.
F. Stay with the child.
Explanation: Staying with the child provides support and ensures the child's safety during the seizure. It also allows the caregiver to observe and provide information to healthcare professionals.
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