The nurse is caring for a patient recovering from a craniotomy. The nurse assists the patient to turn and notes a pink spot with a yellow ring around it on the pillow. What should the nurse do?
a. Change the patient's cranial dressing.
b. Notify the RN immediately.
c. Change the patient's pillowcase.
d. Do a basic neurological assessment.
ANS: B
Drainage that is blood-tinged in the center with a yellowish ring around it may be cerebrospinal fluid (CSF) leakage. A suspected CSF leak should be reported to the RN or physician immediately. A, C, and D can be completed after the RN has been notified. The dressing is changed only with a physician's order.
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What criteria should the nurse use to evaluate to determine if an infant's regurgitation, or spitting up, should be further investigated?
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