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 C
Explanation
A. Varying the child's schedule each day may add unnecessary stress and disrupt the child's sense of routine and stability, which is important during a hospitalization.
B. Providing a daily session with a play therapist may be valuable but does not directly address the child's developmental need for competence and mastery.
C. Encourage the client to complete school work.
Erikson's psychosocial stage theory suggests that children at the age of 10 are in the "Industry vs. Inferiority" stage. During this stage, children strive to develop a sense of competence and mastery in various activities. Encouraging the child to complete school work aligns with this stage, as it fosters a sense of accomplishment, competence, and success, which is crucial for their psychosocial development.
D. Discouraging visits from the client's friends would not support the child's social and emotional well-being during the hospitalization, and social connections are important for psychosocial development.
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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