The nurse is preparing teaching for the parents of a newborn with a newly-placed ventriculoperitoneal shunt. What should the nurse include in this teaching? Select all that apply
Restrict the intake of fruit, vegetables, and fluid
Expect to have the shunt replaced as the child grows
Examine the site every year for signs of swelling or redness
Observe the child for signs of increased intracranial pressure
Notify the health provider if the child develops a fever
Correct Answer : B,D,E
A. Restrict the intake of fruit, vegetables, and fluid: There is no need to restrict the intake of fruit, vegetables, or fluids for a child with a ventriculoperitoneal (VP) shunt. Maintaining proper hydration and nutrition is essential for overall health, and a balanced diet is encouraged.
B. Expect to have the shunt replaced as the child grows: As the child grows, the ventriculoperitoneal shunt may need to be replaced or adjusted to accommodate the growing head and body. This is an important aspect of long-term management of the condition.
C. Examine the site every year for signs of swelling or redness: It is important to monitor the shunt site daily or regularly, more frequently than once a year. Parents should be taught to check the site for signs of infection, swelling, or redness and to notify the healthcare provider if any of these occur.
D. Observe the child for signs of increased intracranial pressure: Increased intracranial pressure (ICP) is a critical concern for children with a VP shunt. Symptoms such as vomiting, lethargy, irritability, or changes in behavior may indicate increased ICP, which requires immediate medical attention.
E. Notify the health provider if the child develops a fever: A fever can be a sign of infection, which could indicate a complication with the shunt, such as an infection of the shunt or its components. Parents should notify the healthcare provider promptly if the child develops a fever.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["107765"]
Explanation
Convert the client's weight from pounds (lb) to kilograms (kg).
Weight in kg = 56.9 lb / 2.2 lb/kg
= 25.8636 kg.
Calculate the total daily dose in units.
Total daily dose (units) = Prescribed dose (units/kg/day) × Weight (kg)
= 25,000 units/kg/day × 25.8636 kg
= 646590 units/day.
Determine the number of doses per day.
Doses are given every 4 hours, so Number of doses per day = 24 hours / 4 hours/dose
= 6 doses/day.
Calculate the dose per administration in units.
Dose per administration (units) = Total daily dose (units) / Number of doses per day
= 646590 units / 6 doses
= 107765 units.
Correct Answer is D
Explanation
A. Notify the health care provider: While notifying the healthcare provider may be necessary if the child's oxygen saturation does not improve, the first step is to assess the child's respiratory status to determine if immediate intervention is needed.
B. Immediately take the child's blood gas: A blood gas may be helpful later, but the priority should be to assess the child's respiratory status and address any immediate concerns with oxygenation before proceeding with more invasive assessments.
C. Give oxygen via face mask at 2 liters per minute: Administering oxygen may be necessary, but the nurse should first assess the child's respiratory status to determine if oxygen supplementation is required and the appropriate delivery method.
D. Assess the child's respiratory status: The most appropriate action is to assess the child's respiratory status. This includes checking for signs of distress, work of breathing, and other factors that could help determine the cause of the low oxygen saturation and guide the appropriate intervention.
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