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. Persistent primitive reflexes (such as the Moro, tonic neck, or grasp reflex) are a hallmark finding in young children with cerebral palsy. Normally, these reflexes disappear as the nervous system matures. Their persistence indicates delayed or abnormal neurological development, which is common in cerebral palsy.
B. Children with cerebral palsy often demonstrate abnormal muscle tone, which may be spastic (increased tone), hypotonic (low tone), or fluctuate between both. Normal tone is not expected.
C. Symmetrical, well-coordinated movements are typically impaired. Children may show asymmetry, abnormal posture, or involuntary movements.
D. Gross motor skill development is often delayed or abnormal due to impaired muscle coordination and tone.
Correct Answer is A
Explanation
A. Giving water after digoxin elixir helps rinse the mouth and teeth, reducing the risk of tooth decay caused by the sweetened solution.
B. Digoxin should not be administered with high-fiber foods, as fiber can decrease its absorption.
C. The nurse should hold digoxin if the heart rate is below 70 BPM in children, not above.
D. Household spoons are inaccurate for dosing; an oral syringe or calibrated device should be used.
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