The nurse reports to the healthcare provider signs of increased intracranial pressure in an infant with myelomeningocele who has which finding?
A fontanelle that bulges with crying
Increased respiratory rate
A high-pitched cry
Tachycardia
The Correct Answer is A
A. A fontanelle that bulges with crying.
Myelomeningocele is a congenital neural tube defect that involves the spinal cord. It is associated with an increased risk of hydrocephalus, which can lead to increased intracranial pressure (ICP). The fontanelle (soft spot) on an infant's head can provide insight into ICP. When an infant with myelomeningocele has an increase in intracranial pressure, the fontanelle may bulge, especially when the infant cries. This is due to the buildup of cerebrospinal fluid within the skull.
B. Increased respiratory rate: While increased intracranial pressure can affect various body systems, an increased respiratory rate is not a specific sign of ICP associated with myelomeningocele.
C. A high-pitched cry: A high-pitched cry is not typically associated with increased intracranial pressure in the context of myelomeningocele. Signs of ICP in infants may include irritability, lethargy, vomiting, and changes in head circumference.
D. Tachycardia: Tachycardia can be a response to stress or discomfort in an infant, but it is not a specific indicator of increased intracranial pressure related to myelomeningocele.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Increased pulse rate.
Iron deficiency anemia can lead to a reduced oxygen-carrying capacity in the blood. As a compensatory mechanism, the heart may pump faster to deliver more oxygen to tissues. This can result in an increased pulse rate. Children with iron deficiency anemia may also experience weakness, fatigue, and pallor.
B. Increased blood pressure is not a common symptom of iron deficiency anemia. In fact, iron deficiency anemia can often lead to lower blood pressure due to the reduced oxygen-carrying capacity of the blood.
C. Warm skin is not a typical symptom of iron deficiency anemia. Skin temperature may not be directly affected by this condition.
D. Cyanosis of the nail beds is not a symptom of iron deficiency anemia. Cyanosis refers to bluish discoloration of the skin or mucous membranes due to reduced oxygen levels in the blood, which is more commonly associated with respiratory or cardiovascular issues. Iron deficiency anemia primarily affects the oxygen-carrying capacity of the blood but does not lead to cyanosis.
Correct Answer is C
Explanation
Option A ("Considering the presence of diabetes but treating the child the same as the other children") is not the best approach because children with diabetes require individualized care and monitoring.
Option B ("Limiting fluid intake during school hours") is not an appropriate intervention and could potentially worsen the child's diabetes management. Hydration is important, and fluid intake should be based on the child's needs.
Option C. Asking the child each day what was eaten for breakfast.
Children with type 1 diabetes, especially those prone to morning hypoglycemic episodes, can benefit from close monitoring of their dietary choices and blood glucose levels. Asking the child what was eaten for breakfast allows the school nurse to assess whether the child had an appropriate meal and whether the insulin dosage may need adjustment. It helps identify potential factors contributing to hypoglycemia and provides valuable information for the child's diabetes management.
Option D ("Checking several times a day for injuries because of participation in the physical education program") is a good practice but does not specifically address the management of morning hypoglycemia. It is essential to monitor the child's safety during physical activities, but addressing breakfast choices and insulin management is more directly related to managing morning hypoglycemia.
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