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 D
Explanation
A.Pyloric stenosis is a condition where there's narrowing of the opening between the stomach and the small intestine. It is not related to inadequate motility of the intestine.
B.Enterocolitis refers to inflammation of the small intestine and colon. While this can cause obstruction in some cases, it's not the primary cause of inadequate motility as seen in the question.
C.Encopresis is the voluntary or involuntary passage of feces outside the toilet in children who should be toilet trained. It is not a cause of mechanical intestinal obstruction.
D. Hirschsprung's disease is a congenital disorder where there is inadequate motility in part of the intestine, leading to mechanical obstruction. It usually affects the colon and is due to the absence of ganglion cells in the affected segment of the bowel.
So, Hirschsprung's disease is the specific condition that leads to inadequate motility and mechanical obstruction of part of the intestine in infants.
Correct Answer is C
Explanation
A. "Your husband is correct. Constant attention makes an infant irritable and spoiled." This statement is not accurate. Infants need responsive caregiving and interaction with their caregivers for healthy emotional development. Providing attention to meet the baby's needs is not synonymous with spoiling.
B. "Your husband is concerned for you as giving so much attention to an infant significantly depletes your energy." While it's true that caring for a baby can be physically demanding and exhausting for parents, this response doesn't address the husband's concern and doesn't provide guidance on infant care.
C. "Your husband is not correct. Interaction helps an infant establish trust."
Option C provides the most appropriate response because it supports the importance of interaction and bonding with the infant, especially during the early stages of development. Establishing trust and attachment with the baby is crucial for their emotional and psychological well-being. Responsive caregiving and interaction with the infant is not associated with spoiling but rather with healthy child development.
D. "Your husband knows what he is talking about. A lot of attention causes a child to become self-centered." This response is not supported by current child development research. Proper attention and interaction with an infant promote healthy attachment and emotional development rather than causing self-centeredness.
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