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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Avoid forcing apart the teeth: Placing objects in the client’s mouth or trying to pry open the teeth can cause injury. It is important to let the seizure pass without interfering with the jaw or mouth.

B. Loosen clothing around the neck: Loosening tight clothing reduces the risk of airway obstruction or restricted breathing during a seizure. This is a correct and helpful intervention.

C. Position the head from injury: Protecting the client’s head with a soft object prevents trauma during convulsions. This is a recommended and safe practice during seizures.

D. Secure the limbs to the body: Restraining or holding down limbs can cause musculoskeletal injuries and increase agitation. Seizure safety protocols emphasize allowing movement without physical restraint.

A. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid. B. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity. C. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds. D. The client with an obstruction of the large intestine who is experiencing abdominal distention.

Correct Answer is B

Explanation

A. While the presence of greenish fluid in a nasogastric tube can indicate a small bowel obstruction, this finding alone does not necessarily indicate an immediate life-threatening condition. The client should be monitored, but this is not the priority.

B. Abdominal rigidity in the context of a volvulus (twisting of the bowel) can indicate bowel ischemia or perforation, which is a surgical emergency. Immediate intervention is needed to prevent further complications such as sepsis or peritonitis.

C. A paralytic ileus is a common postoperative complication and often resolves with time. While the absence of bowel sounds is concerning, it is a routine finding in this situation and does not require immediate attention unless there are signs of further complications.

D. Abdominal distention in a large bowel obstruction can indicate a need for further assessment and treatment. However, compared to a volvulus with abdominal rigidity, this situation is less urgent and does not represent an immediate life-threatening emergency.

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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)]

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Correct Answer is D

Explanation

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Explanation

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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)]