Which action should the nurse take when providing postoperative nursing care to a child after insertion of ventriculoperitone (VP) shunt?
Check the urine for glucose and protein
Administer narcotics for pain control
Test cerebrospinal (CSP) fluid leakage for protein
Monitor for increased temperature
The Correct Answer is D
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.
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Related Questions
Correct Answer is B
Explanation
A. Alertness as such weight loss is not expected: This response may unnecessarily alarm the mother when, in fact, some weight loss in the early days is normal.
B. Reassurance as this is a normal weight loss.
It is normal for newborns to lose some weight during the first few days of life. The loss is often related to fluid loss, changes in feeding patterns, and initial adjustment to life outside the womb. A loss of one-half pound in a 2-day-old neonate is generally considered within the normal range. It's important for the nurse to reassure the new mother that this weight loss is expected and not a cause for alarm. Newborns typically start to regain their birth weight within a week or two. This reassurance can help ease the mother's distress and anxiety.
C. Alarm as this is a drastic weight loss: Characterizing this weight loss as "drastic" is not accurate or helpful and would likely increase the mother's anxiety.
D. Concern as this may be an indicator of inadequate nutrition: Jumping to the conclusion of inadequate nutrition without further assessment and evidence is premature and may unnecessarily worry the mother. It's important to start with reassurance and then investigate if there are concerns about nutrition.
Correct Answer is C
Explanation
A. "Your husband is correct. Constant attention makes an infant irritable and spoiled." This statement is not accurate. Infants need responsive caregiving and interaction with their caregivers for healthy emotional development. Providing attention to meet the baby's needs is not synonymous with spoiling.
B. "Your husband is concerned for you as giving so much attention to an infant significantly depletes your energy." While it's true that caring for a baby can be physically demanding and exhausting for parents, this response doesn't address the husband's concern and doesn't provide guidance on infant care.
C. "Your husband is not correct. Interaction helps an infant establish trust."
Option C provides the most appropriate response because it supports the importance of interaction and bonding with the infant, especially during the early stages of development. Establishing trust and attachment with the baby is crucial for their emotional and psychological well-being. Responsive caregiving and interaction with the infant is not associated with spoiling but rather with healthy child development.
D. "Your husband knows what he is talking about. A lot of attention causes a child to become self-centered." This response is not supported by current child development research. Proper attention and interaction with an infant promote healthy attachment and emotional development rather than causing self-centeredness.
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