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Gmail Which of the following nursing actions should the nurse plan to take A nurse is caring for an infant. postoperatively? For each potential nursing action, click to specify if the potential action Medical History Nurses’ Notes is essential, nonessential, or contraindicated for the infant. Nurses’ Notes Preoperative note: Potential Action Essential Nonessential Contraindicated Infant alert and fussy with high-pitched cry. Anterior fontanel tense and bulging. Scalp veins dilated. Pupils equal and react to light equally. Assess for unilateral pupil O O O dilation. Postoperative note: Infant transferred to unit following the insertion of a ventriculoperitoneal Measure head O O O shunt. Shunt tract observed behind ear and down the neck. Infant circumference daily. sleeping, but easily aroused. Monitor for abdominal O O O distention. Test drainage from O O O incision site for the presence of glucose. Keep the head of bed O elevated 60 to 90 for 48 O O hr. Perform clean intermittent O catheterization every 4 hr. O O Apply a pressure dressing O over the shunt valve. O O PREVIOUS

 
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