A nurse is caring for a newborn who has hydrocephalus.
Which of the following manifestations should the nurse expect to find?

The correct answer is Choice D.

Choice A rationale

Referring the child to social work for early intervention is important, but it is not the immediate priority. The nurse should first discuss the assessment findings with the primary care provider to confirm the diagnosis and plan the next steps.

Choice B rationale

Educating the parents on the developmental delays their child is diagnosed with is essential, but it should come after a confirmed diagnosis and a comprehensive plan is in place. The primary care provider should be involved in this process.

Choice C rationale

Providing the parents with pamphlets for support groups is supportive but not the immediate priority. The nurse should first ensure that the primary care provider is aware of the assessment findings to confirm the diagnosis and plan appropriate interventions.

Choice D rationale

Discussing the assessment findings with the primary care provider is the priority action. This ensures that the child receives a thorough evaluation and appropriate interventions are planned based on a confirmed diagnosis.

Choice A rationale:

Nasal flaring is a sign of respiratory distress. The absence of nasal flaring would indicate improvement, but the presence of nasal flaring indicates ongoing respiratory distress.

Choice B rationale:

Retractions are also a sign of respiratory distress. The reduction or absence of retractions would indicate improvement, but their presence indicates ongoing respiratory distress.

Choice C rationale:

Oxygen saturation is a key indicator of respiratory function. An improvement in oxygen saturation levels (from 89% on room air to higher levels) indicates that the treatment plan is effective in improving the child’s oxygenation.

Choice D rationale:

Breath sounds in bilateral bases are important to assess for improvement in lung function. The presence of clear breath sounds or reduced wheezing indicates improvement in the child’s respiratory status.

Choice E rationale:

Respiratory rate is an important vital sign to monitor in respiratory conditions. A decrease in respiratory rate (from 42 breaths/min to a lower rate) indicates that the treatment plan is effective in reducing the child’s respiratory distress.

Choice F rationale:

Heart rate can be influenced by various factors, including fever, anxiety, and respiratory distress. While a decrease in heart rate may indicate improvement, it is not as specific an indicator of respiratory function as oxygen saturation and respiratory rate.