A 2-day-old infant with hydrocephalus returns from surgery following placement of a ventriculoperitoneal shunt. Which nursing intervention(s) should the practical nurse (PN) implement during postoperative care? (Select all that apply.)
Measure head circumference dally.
Document strict intake and output.
Irrigate shunt and pump valve every 12-hours.
Monitor body temperature every 4-hours.
Correct Answer : A,B,D
A. Measure head circumference daily. - Monitoring head circumference is crucial to detect changes that might indicate increased intracranial pressure after the shunt placement.
B. Document strict intake and output. - Monitoring fluid intake and output helps assess the infant's hydration status and shunt functionality.
C. Irrigate shunt and pump valve every 12-hours. - Shunt irrigation should be performed by specialized healthcare professionals, not typically by a practical nurse.
D. Monitor body temperature every 4 hours. - Postoperative monitoring includes assessing for signs of infection or systemic changes, which might be indicated by changes in body temperature.
E. Place in Trendelenburg position. - The Trendelenburg position is not typically recommended post-ventriculoperitoneal shunt placement and should be avoided unless specifically prescribed by the healthcare provider.
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Related Questions
Correct Answer is B
Explanation
A. Wrapping the infant with a warm blanket might provide comfort but may not directly address the cause of restlessness, grimacing, and drawing knees to the chest.
B. Giving the prescribed analgesic is essential to alleviate the infant's discomfort or pain following a surgical procedure like pylorotomy.
C. Obtaining blood glucose levels might be necessary in certain situations but does not directly address the observed signs of discomfort and pain in the infant.
D. Burping the infant every two hours is not the most appropriate action considering the presented symptoms. Administering the prescribed analgesic is more directly related to addressing the infant's discomfort.
Correct Answer is C
Explanation
A. Checking for kinks in the drainage tubing might be a part of troubleshooting, but the observed clots and thick red fluid require immediate attention, so informing the charge nurse is the priority.
B. Delaying assessment for another hour could potentially exacerbate the issue if there's a problem with the irrigation or if the client's condition worsens.
C. Reporting the finding to the charge nurse is crucial as it indicates potential complications such as bleeding or clot formation that need immediate intervention.
D. Immediately stopping the irrigation solution without proper assessment and guidance could lead to complications and isn't the initial action warranted in this situation.
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