A nurse is caring for a 6-month-old infant who has a subdural hematoma. Which of the following findings should the nurse expect?

Pinpoint pupils

Sunken anterior fontanel

Hypertonia

Vomiting

Answer and Explanation

The Correct Answer is D

A. "Pinpoint pupils." A subdural hematoma typically causes unequal or dilated pupils due to increased intracranial pressure (ICP), rather than pinpoint pupils, which are more commonly associated with opioid toxicity or pontine damage.

B. "Sunken anterior fontanel." A sunken fontanel is a sign of dehydration. In cases of increased ICP, as seen with a subdural hematoma, the anterior fontanel is more likely to be bulging.

C. "Hypertonia." Neurological changes can occur, but hypotonia (decreased muscle tone) is more common in infants with increased ICP rather than hypertonia (increased muscle tone).

D. "Vomiting." Vomiting is a classic sign of increased ICP in infants, which occurs due to the pressure on the brainstem. Other symptoms may include irritability, a bulging fontanel, seizures, and lethargy.

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Correct Answer is C

Explanation

A. Urine output 25 mL/hr – This is an adequate urine output for a school-age child and does not require withholding digoxin.
B. Oxygen saturation 88% – While low, this does not directly indicate digoxin toxicity or require withholding the medication. The underlying cause should be evaluated.
C. Heart rate 64/min – Digoxin can cause bradycardia, and a heart rate of 64/min is too low for a school-age child. Generally, digoxin should be withheld if the heart rate is below 70 bpm in children or below 90 bpm in infants.
D. Respiratory rate 18/min – This is within the normal range for a school-age child and does not warrant withholding digoxin.

A. Monitor for constipation. B. Maintain strict 1&O. C. Initiate airborne precautions. D. Encourage bed rest.

Correct Answer is B

Explanation

A. "Monitor for constipation." Constipation is not a common adverse effect of gentamicin. More concerning side effects include nephrotoxicity and ototoxicity.

B. "Maintain strict I&O." Gentamicin can cause nephrotoxicity, so it is essential to monitor intake and output (I&O) closely to assess kidney function and detect early signs of renal impairment.

C. "Initiate airborne precautions." Gentamicin is an antibiotic and does not require airborne precautions. Airborne precautions are used for infections like tuberculosis, measles, and varicella.

D. "Encourage bed rest." Gentamicin does not require bed rest. However, if the child experiences dizziness due to ototoxicity (another adverse effect), activity may need to be limited.

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A nurse is caring for a 6-month-old infant who has a subdural hematoma. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a school-age child prior to administering digoxin. For which of the following findings should the nurse withhold the medication?

Correct Answer is C

Explanation

A nurse is caring for a child who is to receive the first dose of IV gentamicin. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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