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 C
Explanation
Choice A rationale
Performing the most invasive assessment first can cause distress and fear in a preschooler. It’s generally recommended to start with less invasive procedures to build trust and cooperation.
Choice B rationale
Separating a child from their caregiver during an examination can cause anxiety and fear. It’s often beneficial to have the caregiver present during the examination to provide comfort and reassurance.
Choice C rationale
Allowing a child to role-play using miniature equipment can help alleviate fears and anxieties about the examination. It gives the child a sense of control and understanding of what to expect.
Choice D rationale
While it’s important to explain procedures to a child, using medical terminology can confuse and scare them. It’s better to use simple, age-appropriate language that the child can understand.
Correct Answer is D
Explanation
Choice A rationale
At 10 months, it is normal for an infant to not be able to recognize objects by name. Language development varies greatly among children, and many do not start to understand and respond to simple requests and recognize common objects until around 12 months.
Choice B rationale
The ability to turn pages in a book is a fine motor skill that typically develops around 12 to 18 months. Therefore, it is normal for a 10-month-old infant to not have this ability.
Choice C rationale
Peek-a-boo is a common game that many infants enjoy. However, not all infants may show interest in this game. Lack of interest in peek-a-boo is not necessarily a cause for concern.
Choice D rationale
By 10 months, most infants can sit without support. If a 10-month-old infant does not sit steadily without support, it could indicate a delay in motor development and should be reported to the provider.
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