The nurse is caring for a one-week-old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which finding(s) indicate a postoperative complication? Select all that apply.
Reference Range:
White blood cells (WBC) [9,000 to 10,000/mm3 (9 to 10 x 10^9 /L)]
Leakage of cerebral spinal fluid from the incisional site.
Poor feeding and vomiting.
Abdominal distention.
WBC of 10,000/mm3 (10 x 10^ 9/L).
Hyperactive bowel sounds.
Correct Answer : A,B,C
A. Leakage of cerebral spinal fluid from the incisional site: Leakage of cerebrospinal fluid (CSF) from the incision site is a serious postoperative complication. It could indicate a shunt malfunction or infection, requiring immediate attention.
B. Poor feeding and vomiting: These symptoms may indicate increased intracranial pressure, which can result from a shunt malfunction or infection, both serious complications that need to be addressed immediately.
C. Abdominal distention: Abdominal distention in an infant with a VP shunt can indicate an issue with the peritoneal end of the shunt. This could be due to malabsorption of CSF in the peritoneal cavity, infection (peritonitis), or kinking/blockage of the catheter in the abdomen, leading to accumulation of fluid and distention.
D. WBC of 10,000/mm3 (10 x 10^9/L): A WBC count of 10,000/mm3 is within the normal range for a one-week-old infant. Therefore, this finding does not indicate infection or an inflammatory response and is not a concern in this case.
E. Hyperactive bowel sounds: Hyperactive bowel sounds are typically not associated with a VP shunt complication. This finding is generally indicative of gastrointestinal motility, which is not related to a shunt malfunction or infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
A. Monitor ETT markings between 22 and 26 cm at teeth line: While the placement marking on the ETT can be useful for initial placement, it is not the most reliable way to confirm correct positioning. ETT placement should always be verified by clinical assessment rather than relying solely on measurements.
B. Check for capillary refill of 3 seconds or less: Capillary refill is a general indicator of peripheral circulation and does not directly assess whether the ETT is properly placed in the trachea. It is not useful for confirming ETT placement.
C. Auscultate for presence of bilateral breath sounds: This is a key assessment to confirm that the ETT is properly placed. Bilateral breath sounds indicate that air is entering both lungs, suggesting that the tube is correctly positioned in the trachea and not in the esophagus.
D. Obtain a portable chest x-ray to verify ETT location: A chest x-ray is the gold standard for confirming the correct placement of the ETT. It provides an accurate visual confirmation of the tube’s position relative to the carina and the lungs.
E. Assess for symmetrical chest movement: Symmetrical chest movement is another important assessment to confirm proper ETT placement. If the ETT is correctly placed in the trachea, both sides of the chest will rise and fall equally with each breath, indicating effective ventilation.
Correct Answer is A
Explanation
A. Palpate the client's suprapubic area for distention: The symptoms suggest possible urinary retention, which could be a result of benign prostatic hyperplasia (BPH) or another obstruction. Palpating the suprapubic area for distention is important to assess for urinary retention and determine if the bladder is full.
B. Obtain a urine specimen for culture and sensitivity: Although a urinary tract infection can cause urinary symptoms, the client's presentation is more likely indicative of a physical obstruction such as BPH. A culture might be needed later if infection is suspected.
C. Instruct in effective techniques to cleanse the glans penis: Proper hygiene is important, especially in older adult men, but this is not the most relevant action for the symptoms described. The focus should be on assessing for possible urinary retention or obstruction.
D. Advise the client to maintain a voiding diary for one week: While a voiding diary may provide useful information for monitoring symptoms over time, the immediate priority is to assess for urinary retention and bladder distention.
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