A nurse is assisting with the care of a 2-month-old infant who has a subdural hematoma. Which of the following findings should the nurse expect?
Depressed fontanels
Decreased temperature
Difficult to arouse
Weak cry
The Correct Answer is C
Choice A reason:
A subdural hematoma may not directly affect the fontanels. Depressed fontanels can be a sign of dehydration or other underlying conditions, but they are not specifically associated with a subdural hematoma.
Choice B reason:
A subdural hematoma would not typically cause a decrease in body temperature. This finding may be related to other factors, but it is not a characteristic sign of a subdural hematoma.
Choice C reason:
Correct. A subdural hematoma is a collection of blood between the dura mater and the brain. This can lead to increased intracranial pressure and result in the infant being difficult to arouse.
Choice D reason:
While a weak cry can be an indication of distress or illness in an infant, it is not a specific sign of a subdural hematoma. Other assessments, including neurological signs, are crucial in evaluating the infant's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Administering iron dextran subcutaneously into the vastus lateralis is not the recommended route for this medication. It is typically administered intramuscularly.
Choice B reason:
Correct. The preferred method for administering iron dextran is intramuscularly using the Z-track method. This technique helps prevent leakage of the medication into the subcutaneous tissue.
Choice C reason:
Administering iron dextran subcutaneously into the deltoid is not the preferred route for this medication. It is typically administered intramuscularly.
Choice D reason:
While a 20-gauge needle may be appropriate for intramuscular injections, the Z-track method is the preferred technique for administering iron dextran intramuscularly. The gauge of the needle may vary depending on the specific circumstances and patient characteristics.
Correct Answer is ["C","D","E"]
Explanation
Choice A reason:
Obtaining the infant's weight with their diaper on should be avoided as this can alter the result.
Choice B reason:
Placing a stadiometer on the top of the infant's head to measure their length can harm or distress the infant.
Choice C reason:
Ensuring the scale is at 0 is important in obtaining an accurate weight Choice D reason:
Covering the scale with paper is recommended for hygiene purposes
Choice E reason:
This method provides an accurate measurement of the infant's length.
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