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 sheepskin in pillow under the head.
1,2,4,5
Rationale 1: The infant has congenital hydrocephalus. The nurse should measure and plot occipital-frontal baseline measurements, then measure head circumference once a day.
Rationale 2: The infant has congenital hydrocephalus. Increased bulging and widening of sutures indicate increased intracranial pressure.
Rationale 3: The infant's position should be changed frequently to maintain skin integrity.
Rationale 4: Infants with hydrocephalus are prone to infection.
Rationale 5: The infant has congenital hydrocephalus. The enlarged head should be supported with soft sheepskin to prevent skin breakdown.
You might also like to view...
What will happen if you get involved in a power struggle with an autocratic leader?
1. You will win and your ideas will get praise from your leader. 2. Your individual needs will be met. 3. You and the organization will lose. 4. You will be seen as an individual.
A client who is 16 weeks pregnant states, "I thought the most dangerous time is the first 3 months, so I shouldn't have to worry from now on about any dangers to the baby." An appropriate response by the nurse would be,
a. "There are teratogens that may affect your baby during any stage of development." b. "We really won't be able to say for sure before you have an ultrasound." c. "You don't seem very concerned about your baby's welfare." d. "You're right. You are past the critical point."
Which of the following is an advantage of breastfeeding for the infant?
A) Breast milk is more difficult to digest, so it makes the infant feel fuller longer. B) Breast milk contains antibodies and thus decreases the possibility of gastrointestinal illnesses. C) It takes less effort for an infant to suck at a breast than from a bottle. D) Breast milk leads to firmer stools, increasing bowel tone.
The nurse suspects that a patient recovering from surgery in the postanesthesia recovery unit (PACU) is developing malignant hyperthermia. Place these interventions in the order in which they should be performed.Choice 1. Administer oxygen with a nonrebreather mask.Choice 2. Check IV access.Choice 3. Notify the anesthesia provider.Choice 4. Administer Dantrolene.
Fill in the blank(s) with the appropriate word(s).