The nurse reports to the healthcare provider signs of increased intracranial pressure in an infant with myelomeningocele who has which finding?
A fontanelle that bulges with crying
Increased respiratory rate
A high-pitched cry
Tachycardia
The Correct Answer is A
A. A fontanelle that bulges with crying.
Myelomeningocele is a congenital neural tube defect that involves the spinal cord. It is associated with an increased risk of hydrocephalus, which can lead to increased intracranial pressure (ICP). The fontanelle (soft spot) on an infant's head can provide insight into ICP. When an infant with myelomeningocele has an increase in intracranial pressure, the fontanelle may bulge, especially when the infant cries. This is due to the buildup of cerebrospinal fluid within the skull.
B. Increased respiratory rate: While increased intracranial pressure can affect various body systems, an increased respiratory rate is not a specific sign of ICP associated with myelomeningocele.
C. A high-pitched cry: A high-pitched cry is not typically associated with increased intracranial pressure in the context of myelomeningocele. Signs of ICP in infants may include irritability, lethargy, vomiting, and changes in head circumference.
D. Tachycardia: Tachycardia can be a response to stress or discomfort in an infant, but it is not a specific indicator of increased intracranial pressure related to myelomeningocele.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Introducing new foods every day does not allow sufficient time to monitor for adverse reactions.
B. Waiting 8 to 10 days between introducing new foods is a longer interval than typically recommended. It may unnecessarily delay the introduction of a variety of foods to the infant's diet.
C. 5 to 7 days.
When introducing new foods to an infant, it's important to do so gradually to monitor for any potential allergic reactions or sensitivities. Waiting 5 to 7 days between introducing new foods allows for observation of any adverse reactions, such as allergies or digestive issues. This approach helps in identifying the specific food responsible for any adverse reactions and ensures the infant's safety.
D. Waiting 2 to 3 days is too short of an interval to adequately monitor for adverse reactions. Waiting 5 to 7 days provides a better balance between introducing new foods and monitoring for potential issues.
Correct Answer is D
Explanation
A. Administration of a systemic oral antibiotic and a topical antibiotic may be used, but this option does not address the removal of crusts, which is essential for preventing complications.
B. Administration of a systemic and a topical antifungal is not appropriate for impetigo, as impetigo is caused by bacteria, not fungi.
C. Using an oil-based soap for bathing is not recommended, as it may not effectively remove crusts and pustules associated with impetigo, and it does not have antimicrobial properties necessary for treatment.
D. Removal of crusts with an antimicrobial liquid.
Impetigo is a contagious bacterial skin infection, typically caused by Staphylococcus aureus or Streptococcus pyogenes. It often presents with crusts and pustules on the skin. To prevent complications, it's important to keep the affected areas clean and free from crusts. Gently removing crusts with an antimicrobial liquid and clean cloth helps prevent the spread of infection, allows topical antibiotics to work effectively, and reduces the risk of complications.
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