A nurse is assessing a 4-year-old child who is 2 days postoperative following insertion of a ventriculoperitoneal shunt. Which of the following findings is the nurse's priority?

Urine output of 50 mL in 2 hr

Lethargy

Respiratory rate 24/min

Absent Babinski reflex

Answer and Explanation

The Correct Answer is B

A. Urine output of 50 mL in 2 hr: This is within normal limits for a child and does not indicate an immediate concern.
B. Lethargy: Lethargy is a potential sign of increased intracranial pressure (ICP), which is a critical complication of VP shunt placement and requires immediate intervention.
C. Respiratory rate 24/min: This is within the normal range for a 4-year-old child.
D. Absent Babinski reflex: This is a normal finding in children over 2 years old, as the reflex typically disappears by that age.

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Correct Answer is C

Explanation

A. "The infant exhibits a fear of strangers." Stranger anxiety typically develops around 6 to 9 months of age.
B. "The infant understands the word 'no'." Understanding simple words like "no" begins closer to 9 months to 1 year of age.
C. "The infant has an absent grasp reflex." The grasp reflex begins to disappear by 3 months of age, with voluntary grasping developing by 4 to 5 months.
D. "The infant rolls from their back to their abdomen." Rolling from back to abdomen usually occurs around 5 to 6 months.

A. "if our baby vomits after the feeding, we should administer another dose." B. "We should expect our baby to urinate less frequently while taking this medicine." C. "We should position our baby flat on their back to administer the medication." D. "We should avoid diluting the medicine in a bottle of formula." E. "We can use a medication syringe to place small amounts of medicine into the side of our baby's mouth."

Correct Answer is ["D","E"]

Explanation

A. If the baby vomits, do not administer another dose without consulting the provider to avoid overdosing.
B. There is no expected reduction in urination with GER medications. If decreased urination occurs, it may indicate dehydration or another issue.
C. The baby should not be positioned flat when administering medication to avoid choking or aspiration.
D. Avoid diluting medication in a formula bottle, as the infant may not finish the bottle, leading to incomplete dosing.
E. Administering medication with a syringe ensures accurate dosing and avoids wasting the medicine.

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A nurse is assessing a 4-year-old child who is 2 days postoperative following insertion of a ventriculoperitoneal shunt. Which of the following findings is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a 4-month-old infant at a well-child visit. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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Correct Answer is ["D","E"]

Explanation

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