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","B","C","E"]
Explanation
A. Monitoring level of consciousness (LOC): Monitoring the child's level of consciousness is essential as changes in LOC can be an important indicator of the progression of meningitis.
B. Administration of IV antibiotics: Antibiotics are a critical component of the treatment for bacterial meningitis. Early administration of appropriate antibiotics is crucial to control the infection.
C. Decreasing environmental stimuli: Reducing environmental stimuli, such as noise and light, can help minimize discomfort and agitation in a child with meningitis.
D. Increasing IV fluids above maintenance is not typically part of the standard management of bacterial meningitis. Maintaining hydration and electrolyte balance is important, but increasing fluids significantly above maintenance may not be necessary and should be determined based on the child's clinical condition.
E. Instituting droplet precautions: Bacterial meningitis is contagious, and it is important to isolate the child and implement appropriate infection control measures, including droplet precautions, to prevent the spread of the infection to others.
Correct Answer is C
Explanation
A. Introducing new foods every day does not allow sufficient time to monitor for adverse reactions.
B. Waiting 8 to 10 days between introducing new foods is a longer interval than typically recommended. It may unnecessarily delay the introduction of a variety of foods to the infant's diet.
C. 5 to 7 days.
When introducing new foods to an infant, it's important to do so gradually to monitor for any potential allergic reactions or sensitivities. Waiting 5 to 7 days between introducing new foods allows for observation of any adverse reactions, such as allergies or digestive issues. This approach helps in identifying the specific food responsible for any adverse reactions and ensures the infant's safety.
D. Waiting 2 to 3 days is too short of an interval to adequately monitor for adverse reactions. Waiting 5 to 7 days provides a better balance between introducing new foods and monitoring for potential issues.
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