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. Surgical asepsis (sterile technique) should be used for suctioning to prevent infection, not medical asepsis.
B. Applying suction for no longer than 10 seconds is appropriate to prevent hypoxia and trauma to the airway.
C. Advancing the catheter 2 cm after resistance is met is not advised; the catheter should not be forced beyond resistance to avoid injury.
D. The catheter should not be withdrawn if the client begins coughing; instead, it indicates the need for suctioning. If coughing occurs, the nurse should ensure the patient can breathe and may need to suction carefully.
Correct Answer is C
Explanation
Rationale:
A. Muscle rigidity is not a typical manifestation of digoxin toxicity; it is more commonly associated with other conditions or medications.
B. Constipation can occur but is not a primary sign of digoxin toxicity.
C. Nausea is a common early sign of digoxin toxicity and should be included in the teaching. Other symptoms may include vomiting, visual disturbances, and confusion.
D. Wheezing is not associated with digoxin toxicity; it may suggest respiratory issues or an allergic reaction.