The nurse is caring for a one-week-old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which finding(s) indicate a postoperative complication? Select all that apply.
Reference Range:
White blood cells (WBC) [9,000 to 10,000/mm3 (9 to 10 x 10^9 /L)]
Leakage of cerebral spinal fluid from the incisional site.
Poor feeding and vomiting.
Abdominal distention.
WBC of 10,000/mm3 (10 x 10^ 9/L).
Hyperactive bowel sounds.
Correct Answer : A,B,C
A. Leakage of cerebral spinal fluid from the incisional site: Leakage of cerebrospinal fluid (CSF) from the incision site is a serious postoperative complication. It could indicate a shunt malfunction or infection, requiring immediate attention.
B. Poor feeding and vomiting: These symptoms may indicate increased intracranial pressure, which can result from a shunt malfunction or infection, both serious complications that need to be addressed immediately.
C. Abdominal distention: Abdominal distention in an infant with a VP shunt can indicate an issue with the peritoneal end of the shunt. This could be due to malabsorption of CSF in the peritoneal cavity, infection (peritonitis), or kinking/blockage of the catheter in the abdomen, leading to accumulation of fluid and distention.
D. WBC of 10,000/mm3 (10 x 10^9/L): A WBC count of 10,000/mm3 is within the normal range for a one-week-old infant. Therefore, this finding does not indicate infection or an inflammatory response and is not a concern in this case.
E. Hyperactive bowel sounds: Hyperactive bowel sounds are typically not associated with a VP shunt complication. This finding is generally indicative of gastrointestinal motility, which is not related to a shunt malfunction or infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Wear closed-toe shoes that are comfortable and fit well: Wearing well-fitting shoes helps prevent foot injuries and complications, which are common in people with diabetes due to neuropathy and poor circulation. Foot care is crucial for diabetes management.
B. Obtain an A1C blood test every year to monitor glucose control: The A1C test should be done at least twice a year if the client’s blood sugar is under control, or more often if adjustments are needed.
C. Check blood sugar levels every four to six hours every day: Most individuals with type 2 diabetes need to check blood sugar based on specific times like before meals or once daily, not every few hours.
D. Restrict alcoholic beverages to no more than 1 to 2 per week: Moderate alcohol intake may be allowed in some cases, but more frequent consumption can affect blood sugar. The goal is to limit intake, not restrict to a specific number per week.
Correct Answer is ["83"]
Explanation
Rationale:
Total volume to be infused = 500 mL.
Infusion time in minutes = 2 hours × 60 minutes/hour
= 120 minutes.
Drop factor of the IV administration set = 20 gtt/mL.
- Calculate the flow rate in drops per minute (gtt/min).
Flow rate (gtt/min) = (Total volume (mL) × Drop factor (gtt/mL)) / Infusion time (min)
= (500 mL × 20 gtt/mL) / 120 min
= 10000 / 120 gtt/min
= 83.333... gtt/min.
- Round the answer to the nearest whole number.
= 83 gtt/min
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