Author Question: The nurse is caring for a neonate with an intraventricular hemorrhage. What interventions should the ... (Read 67 times)

geodog55 · **on:** Jun 28, 2018

The nurse is caring for a neonate with an intraventricular hemorrhage. What interventions should the nurse avoid to prevent any increase in intracranial pressure? (Select all that apply.)

a. Keeping the head of the bed flat
b. Keeping the environment quiet
c. Handling the neonate minimally
d. Suctioning the endotracheal tube frequently
e. Maintaining the neonate's head in a midline position

Question 2

The home care nurse is visiting a 6-month-old infant with bronchopulmonary dysplasia (BPD). The nurse assesses the child for which signs of overhydration? (Select all that apply.)

a. Edema
b. Serum sodium of 140 mEq/L
c. Urine specific gravity of 1.008
d. Weight gain of 1 lb in 1 week

Missbam101 · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: A, D
Some nursing procedures increase intracranial pressure (ICP). For example, blood pressure increases significantly during endotracheal suctioning in preterm infants, and head positioning produces measurable changes in ICP. ICP is highest when infants are in the dependent (flat) position and decreases when the head is in a midline position and elevated 30 degrees. Keeping the environment quiet, handling the neonate minimally, and maintaining the neonate's head in a midline position are measures to keep the ICP down.

Answer to Question 2

ANS: A, D
Nurses must be alert to signs of overhydration in an infant with BPD such as changes in weight, electrolytes, output measurements, and urine specific gravity and signs of edema. Six-month-old infants gain around 4 to 5 oz a week. One pound in 1 week would indicate fluid retention. Serum sodium of 140 mEq/L and urine specific gravity of 1.008 are normal values and indicate adequate fluid balance.