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 D
Explanation
A. Brachial artery:
Incorrect: The brachial artery is commonly used for measuring blood pressure in infants but not for assessing heart rate.
B. Radial artery:
Incorrect: The radial artery is not typically used for assessing an infant's heart rate, especially in the clinical setting.
C. Carotid artery:
Incorrect: The carotid artery is not commonly used for assessing an infant's heart rate. It is more commonly used in adults, but in infants, the apex of the heart is the preferred site.
D. Apex of the heart.
Correct Answer: The apex of the heart is the most accurate site for counting an infant's heart rate. It is located at the point of maximum impulse (PMI), which is usually at the fifth intercostal space in the mid-clavicular line.
Correct Answer is C
Explanation
A. Meningococcal polysaccharide vaccine
Explanation: Meningococcal vaccine is recommended for adolescents, particularly before starting college, as it helps protect against meningococcal disease. The conjugate form of the vaccine is usually preferred over the polysaccharide form.
B. Pneumococcal polysaccharide vaccine
Explanation: Pneumococcal vaccine is generally recommended for older adults and individuals with specific medical conditions, but it may not be part of routine immunizations for healthy adolescents.
C. Influenza vaccine
Explanation:
Influenza vaccine is recommended annually for adolescents as part of routine immunizations. It helps protect against the seasonal flu, which can cause significant illness and complications.
D. Bacille Calmette-Guerin (BCG) vaccine
Explanation: BCG vaccine is primarily used in some countries to prevent tuberculosis. It is not routinely administered in the United States as part of standard immunization schedules for adolescents.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.