The nurse recognizes which assessments are appropriate for a 7-week-old infant post-operative Ventriculoperitoneal (VP) shunt? (Select All that Apply.)
Observe the infant's level of consciousness and neurologic status
Assess anterior fontanel
Assess the infant's feeding and tolerance of feedings
Evaluate the infant's hydration status and intake and output
Assess the infant's incision sites for signs of infection or drainage
Place sterile saline soaked dressing over the exposed sac
Monitor the infant's pain level and provide appropriate pain management
Monitor vital signs, including temperature, heart rate, and respiratory rate
Correct Answer : A,B,C,D,E,G,H
A. Monitoring level of consciousness and neurologic status is essential to detect shunt malfunction or increased intracranial pressure.
B. Assessing the anterior fontanel helps identify signs of increased intracranial pressure or shunt malfunction.
C. Feeding patterns and tolerance can reflect neurologic status and overall recovery.
D. Hydration status and intake/output are critical to assess fluid balance and shunt function.
E. Incision sites must be monitored for signs of infection or drainage, which can indicate complications.
F. A sterile saline–soaked dressing is used for myelomeningocele prior to repair, not for VP shunt post-op care.
G. Pain management is vital for comfort and to support recovery.
H. Monitoring vital signs helps identify infection, increased intracranial pressure, or other complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Providing a safe environment and removing any potential hazards is the priority nursing intervention for a hospitalized child with seizures. During a seizure, the child is at greatest risk for injury from falls, hitting nearby objects, or airway obstruction. The nurse should ensure padded side rails, suction and oxygen at the bedside, and close monitoring to maintain safety.
B. Administering antipyretic medication may help in cases of febrile seizures but is not the priority intervention for overall seizure management. Seizures can occur without fever, so this is not universally appropriate.
C. Encouraging physical activity is important for overall health but is not safe during an acute seizure episode. Activity should be supervised and tailored to the child’s condition.
D. Restricting fluid intake is not a standard intervention for seizures unless there is another comorbidity (such as SIADH). Fluid restriction does not prevent seizures
Correct Answer is A
Explanation
A. Inspecting the baby’s genitalia and urethral opening is the priority assessment in hypospadias. Hypospadias is a congenital condition in which the urethral opening is located on the ventral (underside) surface of the penis rather than at the tip. Accurate inspection is essential for confirming the diagnosis, determining severity, and guiding surgical planning. It is also important for educating parents about delaying circumcision, since foreskin tissue may be needed for repair.
B. Checking the baby’s respiratory rate is a routine newborn assessment, but it is not specific to hypospadias and is not the priority focus when this condition is suspected.
C. Measuring head circumference is important in general newborn care to track growth and neurological development but is unrelated to hypospadias.
D. Assessing the baby’s ability to breastfeed is essential in overall newborn health, but it does not address the condition of hypospadias.
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