The nurse is monitoring a child with hydrocephalus who received a repeat ventriculoperitoneal (VP) shunt yesterday. Which assessment finding indicates to the nurse that the shunt is functioning normally?

The child has grown in height since the previous shunt placement.

The child is afebrile with normal vital signs postoperatively.

An intracranial pressure (ICP) monitoring probe is in place.

The child reports no evidence of continuous headaches.

Answer and Explanation

The Correct Answer is D

The absence of continuous headaches in the child indicates that the VP shunt is functioning normally. A VP shunt is used to treat hydrocephalus by draining excess cerebrospinal ﬂuid from the brain to the abdomen. If the shunt is functioning properly, it should relieve pressure on the brain and reduce symptoms such as headaches. The other options (A, B, and C) do not directly indicate whether the shunt is functioning normally or not.

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Correct Answer is B

Explanation

Biliary atresia is a condition that can cause jaundice in newborns and infants, and it can also lead to tea-colored urine due to the presence of bilirubin in the urine. Infants with biliary atresia require further assessment and treatment, including possible surgery, to prevent liver damage and other complications.

A. Intussusception is a condition in which a part of the intestine folds into itself, causing an obstruction, but it does not typically present with jaundice or tea-colored urine.

C. Hirschsprung's disease is a congenital condition that aﬀects the large intestine and can cause bowel obstruction, but it also does not typically present with jaundice or tea-colored urine.

D. Huntington's disease is a genetic neurological disorder that typically does not present in infants and does not cause jaundice or tea-colored urine.

A. The TSH is high because of the low production of T4 by the thyroid. B. The thyroxine level is low because the TSH level is high. C. The thyroid gland does not produce normal levels of thyroxine for several weeks after birth. D. High thyroxine levels normally occur in breastfeeding infants.

Correct Answer is A

Explanation

In a normal infant, T4 levels increase after birth due to stimulation by TSH from the pituitary gland. In this case, the T4 level is low and the TSH level is high, indicating that the thyroid gland is not producing enough T4 in response to TSH stimulation. This suggests that the infant may have congenital hypothyroidism, which requires prompt treatment to prevent developmental delays and other complications.

The low T4 level is not a direct cause of the high TSH level; rather, the high TSH level is a compensatory mechanism to increase T4 production. It is not normal for a breastfeeding infant to have high thyroxine levels. While the thyroid gland may take a few weeks to reach normal function after birth, the persistent low T4 and high TSH levels in this infant suggest a more serious issue.

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The nurse is monitoring a child with hydrocephalus who received a repeat ventriculoperitoneal (VP) shunt yesterday. Which assessment finding indicates to the nurse that the shunt is functioning normally?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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