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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?

A.

Irritability when being held

B.

Heart rate 122/min

C.

Hypoactive bowel sounds

D.

Urine specific gravity 1.018

Answer and Explanation

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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View Related questions

Correct Answer is D

Explanation

Rationale:

A. Bradycardia is not typically associated with pulmonary edema; instead, tachycardia is more common as the body tries to compensate for decreased oxygenation.

B. Wheezing may occur in certain respiratory conditions but is not a classic finding in pulmonary edema; instead, crackles or rales are more expected due to fluid accumulation.

C. Pale, dry skin is not characteristic of pulmonary edema; the client may present with cyanosis or clammy skin due to hypoxia.

D. Pink, frothy sputum is a classic sign of pulmonary edema, indicating fluid in the alveoli and is often associated with acute heart failure.

Correct Answer is C

Explanation

Rationale:

A. Concerns about participation in team sports are important, but they do not directly warrant a request for a high-frequency chest compression vest.

B. Discomfort with nebulizer treatments suggests the need for alternate therapies but does not specifically indicate a need for the vest.

C. A statement regarding a small amount of mucus after percussion therapy suggests that traditional methods of airway clearance may not be effective enough, indicating a need for a high-frequency chest compression vest to help mobilize mucus.

D. A fever may indicate an infection or exacerbation but does not directly relate to the need for a high-frequency chest compression vest.

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