A mother brings her preteen daughter to the clinic for her first female examination. During the health assessment, the nurse should implement which technique to determine if the client has reached the age of menarche?

Choice A reason: "Many infants outgrow the need for a shunt after the neonatal period." is not a correct response that the nurse should provide. This statement is false, as most infants with hydrocephalus will need a shunt for life. Only a small percentage of infants with post-hemorrhagic hydrocephalus may outgrow the need for a shunt .

Choice B reason: "The shunt will be replaced as your child grows to reduce pressure in the brain." is the correct response that the nurse should provide. This statement is true, as the shunt will need to be adjusted or replaced as the child grows to accommodate the changes in the size and shape of the head and the amount of fluid drainage. The nurse should educate the mother about the signs and symptoms of shunt malfunction and the need for regular follow-up visits.

Choice C reason: "Other pathways in the brain will drain fluid after the shunt is removed." is not a correct response that the nurse should provide. This statement is false, as the shunt is not removed unless there is a serious complication or the child no longer needs it. The shunt is a permanent device that bypasses the blocked or impaired pathways in the brain and allows the fluid to drain into the abdomen. Without the shunt, the fluid will accumulate in the brain and cause increased pressure and damage.

Choice D reason: "The shunt will have to be reinserted only if an infection or blockage develops." is not a correct response that the nurse should provide. This statement is false, as the shunt is not removed and reinserted unless there is a serious complication or the child no longer needs it. The shunt is a permanent device that stays in place unless it malfunctions or becomes infected. The nurse should educate the mother about the signs and symptoms of shunt infection and the need for prompt treatment.

Choice A reason: Coffee-ground emesis is not the development that the nurse should monitor for. This is a sign of bleeding in the upper gastrointestinal tract, which can be caused by ulcers, gastritis, or esophageal varices. It is not related to the infant's condition, which is likely pyloric stenosis, a narrowing of the opening between the stomach and the small intestine.

Choice B reason: Frequent pauses are not the development that the nurse should monitor for. This is a normal behavior for infants during feeding, as they need to take breaks to breathe and swallow. It is not indicative of any problem or complication.

Choice C reason: Projectile vomiting is the development that the nurse should monitor for. This is a common symptom of pyloric stenosis, a condition that affects about 3 out of 1,000 infants. It occurs when the muscle at the end of the stomach becomes thickened and blocks the passage of food into the small intestine. This causes the infant to vomit forcefully after feeding, leading to dehydration, hunger, and weight loss. The olive-like mass in the upper right abdomen is the enlarged pylorus muscle that can be felt through the skin.

Choice D reason: Arched back is not the development that the nurse should monitor for. This is a sign of pain or discomfort in infants, which can have various causes, such as colic, reflux, or ear infection. It is not specific to pyloric stenosis, although the infant may arch their back due to the abdominal pain caused by the condition. .