The nurse is caring for a 4-month-old infant in the emergency department. The nurse reviews the infant's medical record and assessment findings. Which of the following conditions should the nurse suspect, and what actions should the nurse take to address that condition, and what parameters should the nurse monitor to assess the infant's progress?
The nurse should suspect that the infant has
meningitis.
hydrocephalus.
intracranial hemorrhage.
sepsis.
The Correct Answer is A
Choice A reason: Meningitis is a possible condition, as it is an inflammation of the membranes that cover the brain and spinal cord. It can be caused by various microorganisms, such as bacteria, viruses, or fungi. The infant has many signs and symptoms of meningitis, such as fever, irritability, lethargy, bulging fontanel, and clear cerebrospinal fluid from the lumbar puncture.
Choice B reason: Hydrocephalus is not a likely condition, as it is an accumulation of cerebrospinal fluid in the brain, which causes increased intracranial pressure and enlargement of the head. The infant has a bulging fontanel, which can indicate increased intracranial pressure, but not necessarily hydrocephalus. The infant does not have other signs of hydrocephalus, such as a rapidly increasing head circumference, prominent scalp veins, or sunset eyes.
Choice C reason: Intracranial hemorrhage is not a probable condition, as it is a bleeding within the skull, which can result from trauma, vascular malformation, or coagulation disorder. The infant has retinal hemorrhages, which can indicate intracranial hemorrhage, but not necessarily. The infant does not have other signs of intracranial hemorrhage, such as seizures, vomiting, or altered mental status.
Choice D reason: Sepsis is not a definite condition, as it is a systemic inflammatory response to an infection, which can cause organ dysfunction and shock. The infant has a fever, which can indicate sepsis, but not necessarily. The infant does not have other signs of sepsis, such as tachycardia, tachypnea, hypotension, or poor perfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Holding the infant's chin to his chest and knees to his abdomen during the procedure is not a correct action for the nurse to take. This position may cause spinal cord compression or respiratory distress in the infant. The nurse should position the infant on his side with his back arched and his head and knees flexed.
Choice B reason: Placing the infant in an infant seat for 2 hr following the procedure is not a correct action for the nurse to take. This position may increase the intracranial pressure and cause headaches or vomiting in the infant. The nurse should keep the infant flat or slightly elevated for 4 to 6 hr after the procedure.
Choice C reason: Keeping the infant NPO for 6 hr prior to the procedure is not a correct action for the nurse to take. This may cause dehydration or hypoglycemia in the infant. The nurse should follow the provider's orders for fasting, which are usually 2 to 4 hr for clear liquids and 4 to 6 hr for solids.
Choice D reason: Applying a eutectic mixture of lidocaine and prilocaine cream topically 15 min prior to the procedure is a correct action for the nurse to take. This is a topical anesthetic that can reduce the pain and discomfort of the needle insertion. The nurse should apply the cream to the lower back and cover it with an occlusive dressing.
Correct Answer is D
Explanation
Choice A reason: This is not a correct instruction for the nurse to include in the teaching plan. The parents should not remove the harness when bathing the infant, as this may interrupt the treatment and cause complications. The nurse should instruct the parents to sponge bathe the infant while wearing the harness, and to keep the harness clean and dry.
Choice B reason: This is not a correct instruction for the nurse to include in the teaching plan. The parents should not adjust the straps of the Pavlik harness by themselves, as this may affect the position and stability of the infant's hips. The nurse should instruct the parents to bring the infant to the provider's office regularly for check-ups and adjustments of the harness.
Choice C reason: This is not a correct instruction for the nurse to include in the teaching plan. The parents should not place a thin layer of clothing under the straps of the harness, as this may interfere with the proper alignment and function of the harness. The nurse should instruct the parents to dress the infant in loose-fitting clothing over the harness, and to avoid using bulky or cloth diapers.
Choice D reason: This is a correct instruction for the nurse to include in the teaching plan. The parents should check the infant's skin under the straps of the harness for redness or irritation, as this may indicate skin breakdown or infection. The nurse should instruct the parents to keep the infant's skin clean and dry, and to report any signs of redness, swelling, or drainage.
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