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)]

A. A child with asthma, who takes prednisone and has a fasting serum glucose of 180 mg/dL (10 mmol/L): This client’s fasting glucose is well above the normal range. Prednisone can increase blood glucose levels, placing the child at risk for hyperglycemia. This indicates a need for urgent education on blood glucose management while on steroids.

B. An adolescent male who has type 1 diabetes and a random glucose at 120 mg/dL (6.7 mmol/L): This blood glucose level is within normal limits for random testing. No immediate need for change in diabetic teaching is evident based on this value.

C. A female who has gestational diabetes and has a 1-hour postprandial glucose at 140 mg/dL (7.8 mmol/L): Her result meets the upper limit range for gestational diabetes. While she requires ongoing monitoring, her values do not indicate a need for urgent intervention.

D. An adult who has type 2 diabetes and has a glycosylated hemoglobin (Hb A1C) at 10%: Although this indicates poor long-term control, it reflects a chronic issue. The child with an acutely elevated fasting glucose and corticosteroid use is at greater immediate risk and thus has higher priority for education.

A. Monitor ETT markings between 22 and 26 cm at teeth line: While the placement marking on the ETT can be useful for initial placement, it is not the most reliable way to confirm correct positioning. ETT placement should always be verified by clinical assessment rather than relying solely on measurements.

B. Check for capillary refill of 3 seconds or less: Capillary refill is a general indicator of peripheral circulation and does not directly assess whether the ETT is properly placed in the trachea. It is not useful for confirming ETT placement.

C. Auscultate for presence of bilateral breath sounds: This is a key assessment to confirm that the ETT is properly placed. Bilateral breath sounds indicate that air is entering both lungs, suggesting that the tube is correctly positioned in the trachea and not in the esophagus.

D. Obtain a portable chest x-ray to verify ETT location: A chest x-ray is the gold standard for confirming the correct placement of the ETT. It provides an accurate visual confirmation of the tube’s position relative to the carina and the lungs.

E. Assess for symmetrical chest movement: Symmetrical chest movement is another important assessment to confirm proper ETT placement. If the ETT is correctly placed in the trachea, both sides of the chest will rise and fall equally with each breath, indicating effective ventilation.