An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period?

Test the urine for protein

Reposition the infant frequently.

Assess blood pressure every 15 minutes

Provide a stimulating environment

Answer and Explanation

The Correct Answer is B

A. Test the urine for protein.
Explanation: Testing urine for protein is not a priority nursing intervention in the preoperative period for an infant with hydrocephalus. The focus is on preventing complications related to immobility and positioning.
B. Reposition the infant frequently.
Explanation:
Repositioning the infant frequently is a crucial intervention to prevent complications such as pressure ulcers (bedsores). Infants with hydrocephalus may be at an increased risk of skin breakdown due to prolonged immobility and pressure on specific areas. Repositioning helps distribute pressure, improves circulation, and reduces the risk of skin breakdown.
C. Assess blood pressure every 15 minutes.
Explanation: While monitoring blood pressure is important in certain situations, it is not typically the priority for an infant with hydrocephalus in the preoperative period. The focus is on preventing skin breakdown through repositioning.
D. Provide a stimulating environment.
Explanation: While providing a stimulating environment can be beneficial for infant development, it is not the priority in the preoperative period for an infant with hydrocephalus. The primary concern is addressing potential complications related to immobility, such as skin breakdown.

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Correct Answer is A

Explanation

A. "This test will confirm if your child had a recent streptococcal infection."
Explanation:
The anti-streptolysin O (ASO) titer is a blood test used to detect the presence of antibodies against streptolysin O, a toxin produced by group A Streptococcus bacteria. A rise in ASO titers indicates a recent streptococcal infection. It does not confirm rheumatic fever directly but helps in identifying a recent streptococcal infection, which is a predisposing factor for rheumatic fever.
B. "This test will indicate if your child has rheumatic fever."
Explanation: While a positive ASO titer may suggest a recent streptococcal infection, it does not directly indicate rheumatic fever. The diagnosis of rheumatic fever involves a combination of clinical criteria, including evidence of a recent streptococcal infection, along with specific signs and symptoms.
C. "This test will confirm if your child has immunity to streptococcal bacteria."
Explanation: The ASO titer does not measure immunity to streptococcal bacteria. It specifically detects antibodies produced in response to a recent streptococcal infection.
D. "This test will indicate if your child has a therapeutic blood level of an aminoglycoside."
Explanation: The ASO titer is not used to monitor therapeutic blood levels of aminoglycosides. It is specific to detecting antibodies related to streptococcal infections and is not related to aminoglycoside therapy.

A. Brachial artery B. Radial artery C. Carotid artery D. Apex of the heart

Correct Answer is D

Explanation

A. Brachial artery:
Incorrect: The brachial artery is commonly used for measuring blood pressure in infants but not for assessing heart rate.
B. Radial artery:
Incorrect: The radial artery is not typically used for assessing an infant's heart rate, especially in the clinical setting.
C. Carotid artery:
Incorrect: The carotid artery is not commonly used for assessing an infant's heart rate. It is more commonly used in adults, but in infants, the apex of the heart is the preferred site.
D. Apex of the heart.
Correct Answer: The apex of the heart is the most accurate site for counting an infant's heart rate. It is located at the point of maximum impulse (PMI), which is usually at the fifth intercostal space in the mid-clavicular line.

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An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who was admitted with suspected rheumatic fever. The provider prescribes an anti-streptolysin O (ASO) titer. The parent asks the nurse the purpose of the test. Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is preparing to measure an infant's vital signs. The nurse should use which of the following sites to assess a heart rate?

Correct Answer is D

Explanation

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