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 D
Explanation
A. Checking urine for glucose and protein is not directly related to the care of a child with a VP shunt. The focus is on monitoring the child for signs of complications related to the shunt.
B. Administering narcotics for pain control may be indicated if the child is in pain, but it is not the primary action and should be determined based on the child's pain assessment.
C. Testing cerebrospinal (CSF) fluid leakage for protein is not typically a nursing responsibility in the immediate postoperative period. Leakage of CSF should be reported to the healthcare provider, and diagnostic tests would be conducted by medical staff as needed.
D. Monitor for increased temperature.
Monitoring for an increased temperature is essential because postoperative fever could be an early sign of infection or complications related to the VP shunt. Infection and shunt malfunction are potential risks in the postoperative period.
Correct Answer is A
Explanation
A.Growth of that leg may be affected.
When a fracture occurs near the epiphyseal plate of a long bone, such as the femur, there is a risk of damage to the growth plate. The growth plate (epiphyseal plate) is responsible for longitudinal bone growth in children. If the growth plate is injured or damaged during the fracture, it can potentially lead to growth disturbances and affect the growth of that leg.
B. Risk for infection at this location is increased: While any fracture has a risk of infection, the proximity to the epiphyseal plate doesn't necessarily increase the risk of infection.
C. Long bones contain marrow, which increases the risk for anemia: The presence of bone marrow in long bones is unrelated to the potential effects on bone growth after a fracture near the epiphyseal plate.
D. Fracture repair will necessitate prolonged traction: The use of traction for fracture repair can vary depending on the type and location of the fracture. However, the primary concern with a fracture near the epiphyseal plate is its potential impact on bone growth.
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