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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Avoid massaging the skin under the straps." Gentle massage is recommended to promote circulation and prevent skin breakdown.
B. "Use lotion on the skin under the harness." Lotion or powders should be avoided because they can cause skin irritation and breakdown.
C. "Adjust the harness straps weekly." Only the healthcare provider should adjust the straps to ensure proper hip positioning.
D. "Place the diaper under the straps." This helps keep the harness clean and dry, preventing skin irritation and breakdown.
Correct Answer is B
Explanation
A. Heart rate – No data regarding heart rate is provided in the exhibit, so this is not a relevant option.
B. HbA1c – The child's HbA1c level is 8.5%, which is elevated above the normal range (4% to 5.9%). This indicates poor glycemic control, suggesting the development of cystic fibrosis-related diabetes (CFRD), a common complication of cystic fibrosis. This should be reported to the provider for further evaluation and management.
C. WBC count – The WBC count is 9,600/mm³, which is within the normal range (5,000 to 10,000/mm³), so it does not require reporting.
D. Oxygen saturation – No data regarding oxygen saturation is provided in the exhibit, making this option irrelevant.
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