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
Explanation
Choice A rationale
Uterine atony refers to a soft and weak uterus after childbirth. It happens when your uterine muscles don’t contract enough to clamp the placental blood vessels shut after childbirth. This can lead to life-threatening blood loss after delivery. One of the causes of uterine atony is urinary retention. When the bladder is full, it can displace the uterus, preventing it from contracting properly. This can lead to uterine atony and postpartum hemorrhage. Therefore, urinary retention can cause uterine atony and lateral displacement of the fundus.
Choice B rationale
Poor involution of the uterus is a condition where the uterus does not return to its normal size after childbirth. While poor involution can lead to prolonged bleeding, it does not directly cause uterine atony. Uterine atony is specifically a lack of muscle contraction, while poor involution is a failure of the uterus to reduce in size.
Choice C rationale
While infection can lead to many complications during the postpartum period, it is not a direct cause of uterine atony. Infections can cause endometritis, which is inflammation of the uterine lining, but this does not prevent the uterus from contracting.
Choice D rationale
Hemorrhage, or heavy bleeding, is a result of uterine atony, not a cause. When the uterus does not contract properly after childbirth, it can lead to excessive bleeding, or hemorrhage.
Correct Answer is A
Explanation
Choice A rationale
Tetralogy of Fallot is a congenital heart defect that includes four specific heart abnormalities: pulmonic stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy.
Choice B rationale
This choice incorrectly identifies aortic stenosis and atrial septal defect as components of Tetralogy of Fallot. In fact, the condition involves pulmonic stenosis and a ventricular septal defect.
Choice C rationale
This choice incorrectly identifies pulmonary stenosis and aortic hypertrophy as components of Tetralogy of Fallot. In fact, the condition involves pulmonic stenosis and right ventricular hypertrophy.
Choice D rationale
This choice incorrectly identifies aortic stenosis as a component of Tetralogy of Fallot. In fact, the condition involves pulmonic stenosis.
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