An infant develops hydrocephalus at 2 weeks of age. Which finding would the nurse expect to assess?

Hypothermia in the late afternoon

Excessive thirst

White sclera showing above the pupils

A soft, fretful cry

Answer and Explanation

The Correct Answer is C

A. Hypothermia in the late afternoon: Hypothermia is not typically associated with hydrocephalus. Hydrocephalus primarily affects the neurological system, leading to increased intracranial pressure rather than issues with body temperature regulation.

B. Excessive thirst: Excessive thirst is not a common sign of hydrocephalus. Hydrocephalus is more associated with neurological symptoms and signs related to increased intracranial pressure, such as changes in behavior, bulging fontanels, and irritability.

C. White sclera showing above the pupils: This finding, known as "sunsetting" eyes, is a classic sign of hydrocephalus. It occurs due to increased pressure in the brain, causing the eyes to deviate downward, with the sclera (white part of the eye) visible above the pupils.

D. A soft, fretful cry: While infants with hydrocephalus may exhibit irritability or a high-pitched cry, a "soft, fretful cry" is not a characteristic or specific finding. The cry may be more piercing or abnormal if the baby is experiencing increased intracranial pressure.

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Correct Answer is C

Explanation

A. Pressure from the growing uterus displaces the stomach: While the growing uterus does exert pressure on the stomach later in pregnancy, heartburn (acid reflux) at 10 weeks is more likely due to hormonal changes rather than uterine displacement, which typically becomes more noticeable in the second trimester.

B. Increased estrogen production causes increased secretion of hydrochloric acid: Increased estrogen levels during pregnancy are not linked to increased hydrochloric acid secretion as the primary cause of heartburn. While hormones do play a role, it's not typically through enhanced acid production.

C. Increased progesterone production during pregnancy slows gastrointestinal motility: Progesterone is the main hormone responsible for slowing gastrointestinal motility, leading to delayed gastric emptying and relaxation of the lower esophageal sphincter, which can cause heartburn or acid reflux.

D. Retained bile in the liver results in delayed digestion: This is not a primary cause of heartburn during pregnancy. Delayed digestion due to hormonal effects, particularly from progesterone, is the more likely cause of heartburn in the early stages of pregnancy.

A. Abdominal discomfort B. Intestinal obstruction C. Contaminating flatulence D. Pressure on the incision line

Correct Answer is D

Explanation

A. Abdominal discomfort: While burping can help relieve some discomfort after feeding, the primary concern following pyloric stenosis surgery is avoiding pressure on the incision line, rather than just abdominal discomfort.

B. Intestinal obstruction: Burping after feedings can help reduce the buildup of air in the stomach, but it is not directly aimed at preventing intestinal obstruction. Obstruction is more related to the surgical site and healing process, not the burping.

C. Contaminating flatulence: Flatulence is not a concern related to burping after pyloric stenosis surgery. Burping is done to release air swallowed during feeding, not to manage flatulence.

D. Pressure on the incision line: Burping helps to release any air swallowed during feeding, reducing abdominal distention and minimizing pressure on the surgical site. This is important to ensure proper healing and comfort after the procedure.

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An infant develops hydrocephalus at 2 weeks of age. Which finding would the nurse expect to assess?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the prenatal clinic is caring for a client who is at 10 weeks gestation. During the visit the client asks about the cause of their heartburn. The nurse would provide which of the following responses?

Correct Answer is C

Explanation

Following surgery for pyloric stenosis, an infant should be burped well following feedings primarily to prevent:

Correct Answer is D

Explanation

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