A nurse is assessing an infant who has hydrocephalus and is 6 hr postoperative following placement of a ventriculoperitoneal (VP) shunt. Which of the following findings should the nurse report to the provider?
Irritability when being held
Heart rate 122/min
Hypoactive bowel sounds
Urine specific gravity 1.018
The Correct Answer is A
Rationale:
A. Irritability when being held may indicate increased intracranial pressure or complications related to the VP shunt placement and should be reported to the provider.
B. A heart rate of 122/min is within the normal range for an infant and does not require reporting.
C. Hypoactive bowel sounds may occur postoperatively, especially if the infant has not been fed or has been under anesthesia, and is not an immediate concern.
D. A urine specific gravity of 1.018 is within normal limits for infants and does not indicate a need for reporting.
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Correct Answer is B
Explanation
Rationale:
A. Hypotension is not a common adverse effect of estradiol; instead, it may cause hypertension.
B. Bruising can indicate thrombocytopenia or other clotting issues, which are serious adverse effects of estradiol and should be reported immediately.
C. Headaches are a common side effect of estradiol but are usually not severe; they typically do not require reporting unless they are persistent or severe.
D. Oliguria is not a known adverse effect of estradiol and may indicate other underlying issues that are unrelated to this medication.
Correct Answer is B
Explanation
Rationale:
A. While restricting visits from young children may help reduce infection risk, it is not a sufficient or specific intervention for neutropenic precautions.
B. Avoiding raw fruits is critical because they can harbor bacteria and increase the risk of infection in neutropenic clients. Cooked fruits are safer options.
C. Measuring temperature should occur more frequently than every 8 hours, ideally every 4 hours or more, to quickly identify fever, a sign of infection.
D. Disposable gloves should be used from within the client's room to maintain strict infection control measures; using gloves from outside could introduce contaminants.