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 A

Explanation

A. Obtain a blood culture. The first action is to obtain a blood culture to identify the causative organism before starting antibiotic therapy. This ensures that the appropriate antibiotic is selected.
B. Request a referral for physical therapy. Physical therapy may be needed later, but it is not the priority during admission.
C. Administer IV antibiotics. Antibiotics should be given after obtaining a blood culture to avoid altering the test results.
D. Record intake and output. While monitoring fluid balance is important, it is not the priority action during admission.

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?

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