A nurse is contributing to the plan of care for a toddler who is receiving intermittent enteral feedings. Which of the following interventions should the nurse include?

Rationale for Correct Choices:

• Increased Intracranial Pressure: The infant's symptoms (irritability, vomiting, bulging anterior fontanel, and tense fontanel) suggest increased intracranial pressure, a potential complication of hydrocephalus and ventriculoperitoneal shunt malfunction.
• Measure head circumference: Measuring head circumference is essential in assessing for increased intracranial pressure, as it can help identify changes in the volume of the head due to fluid buildup.
• Insert nasogastric tube: Inserting a nasogastric tube is often necessary to manage vomiting and ensure adequate hydration and nutrition, especially when the infant is unable to feed properly due to increased intracranial pressure.
• Behavioural changes: Monitoring for changes in behaviour, such as lethargy or decreased responsiveness, is critical in assessing the progression of increased intracranial pressure.
• Pupillary response: Pupillary response is an important parameter to monitor because changes in the size, shape, and reactivity of the pupils can indicate increased intracranial pressure or brainstem involvement.

Rationale for Incorrect Choices:

• Paralytic ileus: While the infant is having stool issues, the primary symptoms of irritability, vomiting, and bulging fontanel are more indicative of increased intracranial pressure. Paralytic ileus is generally associated with absent bowel sounds and abdominal distension.
• Otitis media: Otitis media typically presents with fever, ear pain, and irritability, but the infant’s bulging fontanel, vomiting, and irritability are more suggestive of intracranial pressure. Otitis media does not cause neurological symptoms like a tense fontanel.
• Peritonitis: Peritonitis usually presents with abdominal distension, guarding, or signs of sepsis, which are not evident here. The infant’s symptoms point more towards neurological issues related to the ventriculoperitoneal shunt or increased intracranial pressure.
• Prepare the infant for myringotomy: Myringotomy is performed for severe ear infections with fluid accumulation behind the eardrum (otitis media), but the infant's presentation suggests a neurological issue, not an ear infection.
• Place the child in an infant seat: Placing the infant in an infant seat may provide temporary comfort but does not address the underlying neurological issue, and this action does not help manage the potential condition.
• Plan to assist with the administration of intravenous antibiotics: While infection (e.g., shunt infection leading to hydrocephalus) is a possibility, the immediate nursing actions focus on confirming and managing the elevated ICP.
• Bowel sounds: Monitoring bowel sounds is more relevant to gastrointestinal conditions, such as paralytic ileus or peritonitis, which are not the primary concern here.
• Tympanic perforation relates to an ear condition and is not a relevant parameter for monitoring increased intracranial pressure.
• Abdominal distension: Abdominal distension is usually associated with gastrointestinal problems like peritonitis or paralytic ileus. However, the infant’s clinical presentation (neurological symptoms) suggests increased intracranial pressure.

A. Gently cleanse the surgical site with sterile gauze: direct vigorous cleansing of the palate surgical site with gauze is generally avoided to prevent disruption of sutures. Oral rinses or specific gentle cleaning methods may be prescribed, but direct gauze wiping is usually not recommended.
B. Offer a pacifier with glucose syrup: acifiers and any sucking on objects (including straws, spoons, or toys) are typically contraindicated after cleft palate repair because the sucking motion puts stress on the suture line and can disrupt healing.
C. Apply elbow immobilizers to both arms: Elbow immobilizers prevent the infant from bending their elbows and bringing their hands to their mouth or face, which could disrupt the surgical sutures, cause trauma, or introduce infection to the delicate palate repair.
D. Place the infant in a supine position: A semi-upright position is usually preferred to reduce pressure on the surgical site and prevent aspiration, rather than placing the infant flat on their back.