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
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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Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
The infant is at risk for developing aspiration pneumonia and esophageal strictures.
Rationale:
- Aspiration pneumonia: GER can cause stomach contents to enter the respiratory tract, leading to aspiration pneumonia.
- Esophageal strictures: Chronic irritation from stomach acid can result in scarring and narrowing of the esophagus.
Correct Answer is D
Explanation
A. "Flat anterior fontanel." A sunken anterior fontanel, not flat, is a sign of severe dehydration in infants.
B. "Dry, hot skin." Dry skin is a symptom of dehydration, but "hot" skin may indicate fever rather than severe dehydration.
C. "Loss of 5% of weight." A 5% weight loss indicates mild dehydration; severe dehydration is characterized by a weight loss of 10% or more.
D. "Absence of tears when crying." Absence of tears is a reliable indicator of severe dehydration in infants.
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