A nurse is evaluating an infant following a motor vehicle accident.
Which signs should the nurse monitor to detect increased intracranial pressure?
Depressed fontanels
Brisk pupillary reaction to light
Increased sleeping
Unspecified symptom
The Correct Answer is D
Choice A rationale
Depressed fontanels are not typically associated with increased intracranial pressure (ICP) in infants. In fact, bulging fontanels may be a sign of increased ICP1516.
Choice B rationale
A brisk pupillary reaction to light is not a specific sign of increased ICP in infants. Changes in pupillary reaction can occur in various conditions and are not definitive indicators of increased ICP.
Choice C rationale
Increased sleeping is a symptom of increased ICP in infants. However, this symptom alone is not enough to diagnose increased ICP as it can be seen in other conditions as well.
Choice D rationale
Unspecified symptom is not a valid choice as it does not provide a specific symptom to evaluate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Flushing and sweating can be an indication of magnesium sulfate toxicity. Magnesium sulfate is a medication used to prevent seizures in women with severe preeclampsia. However, if the levels of magnesium become too high, it can lead to toxicity15.
Choice B rationale
A decreased level of consciousness can be an indication of magnesium sulfate toxicity. High levels of magnesium can affect the central nervous system, leading to drowsiness, lethargy, and decreased responsiveness15.
Choice C rationale
Urinary output less than 30 mL/hr can be an indication of magnesium sulfate toxicity. Magnesium sulfate can affect kidney function, leading to decreased urine output15.
Choice D rationale
Respirations fewer than 12/min can be an indication of magnesium sulfate toxicity. High levels of magnesium can depress the respiratory system, leading to slow or shallow breathing15.
Correct Answer is C
Explanation
Choice A rationale
Limiting noise and interruption in the delivery room can help create a calm environment, which can be beneficial for both the mother and the newborn. However, this is not the priority action for promoting maternal-infant bonding.
Choice B rationale
Encouraging parents to touch and explore the neonate’s features can help foster a connection between the parents and the newborn. This tactile stimulation can also be comforting for the newborn. However, this is not the most immediate action to promote maternal-infant bonding.
Choice C rationale
Placing the neonate skin-to-skin on the client’s chest is the priority action. Skin-to-skin contact immediately after birth helps regulate the newborn’s temperature, heart rate, and breathing. It also promotes breastfeeding and bonding.
Choice D rationale
Placing the neonate at the client’s breast can promote breastfeeding, which can enhance maternal-infant bonding. However, this is not the first action to take. The priority is to establish skin-to-skin contact.
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