The nurse is caring for a newborn with full fontanelles and "setting sun" eyes. Which nursing interventions should be included in the care plan? Note: Credit will be given only if all correct choices and no incorrect choices are selected
Select all that apply. 1. Measure head circumference daily.
2. Assess for bulging fontanelles.
3. Avoid position changes.
4. Watch for signs of infection.
5. Use a gel pillow under the head.
1, 2, 4, 5
Explanation: 1. The infant has congenital hydrocephalus. The nurse should measure and plot occipital-frontal baseline measurements, then measure head circumference once a day.
2. The infant has congenital hydrocephalus. Fontanelles should be checked for bulging and sutures for widening.
4. Infants with hydrocephalus are prone to infection.
5. The infant has congenital hydrocephalus. The enlarged head should be supported with a gel pillow.
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