A nurse is collecting data from an infant who has hydrocephalus.
Which of the following findings should the nurse expect?
Soft and flat fontanels.
Proteinuria.
Dilated scalp veins.
Hypertension.
The Correct Answer is C
Choice A rationale: Soft and flat fontanels are normal in healthy infants. In hydrocephalus, increased intracranial pressure causes bulging fontanels due to excess cerebrospinal fluid accumulation.
Choice B rationale: Proteinuria is a renal finding and not associated with hydrocephalus. Hydrocephalus affects the central nervous system, not kidney filtration or protein excretion.
Choice C rationale: Dilated scalp veins occur due to elevated intracranial pressure from cerebrospinal fluid buildup. Venous distension is a visible sign in infants with hydrocephalus.
Choice D rationale: Hypertension is not a typical sign of hydrocephalus in infants. The condition primarily presents with neurological and cranial changes, not systemic blood pressure elevation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Measuring from the back of the head to the forehead is not the correct method for measuring head circumference in an infant. The measurement should be taken around the widest part of the head, which is typically above the eyebrows and ears.
Choice B rationale
Placing the measuring tape above the eyebrows and around the widest part of the head is the correct method for measuring head circumference in an infant. The tape should be wrapped around the head at the points just above the eyebrows, above the ears, and around the back where the head slopes up prominently from the neck.
Choice C rationale
Measuring from the chin to the top of the head is not the correct method for measuring head circumference in an infant. The measurement should be taken around the widest part of the head, which is typically above the eyebrows and ears.
Choice D rationale
Wrapping the measuring tape tightly around the neck is not the correct method for measuring head circumference in an infant. The measurement should be taken around the widest part of the head, which is typically above the eyebrows and ears.
Correct Answer is B,D,A,C
Explanation
The correct order of Erikson’s stages of growth is B, D, A, C.
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