A nurse is preparing to administer an oral elixir to a 3-month-old infant using an oral medication syringe.
Which of the following actions should the nurse take?

Choice A rationale

This response is inappropriate and unprofessional. It makes an assumption about the child’s behavior at home without any evidence. It also could make the parents feel blamed or judged, which is not conducive to a supportive healthcare environment.

Choice B rationale

While it’s important for the nurse to communicate with the provider about any changes in the child’s health status, this response does not directly address the parents’ concern. It also does not provide reassurance or information about why the bedwetting might be occurring.

Choice C rationale

This response is empathetic and informative. It normalizes the child’s behavior by explaining that regression is common in hospitalized children. It also reassures the parents that the bedwetting is likely temporary and will improve as the child recovers.

Choice D rationale

While this response is empathetic, it does not directly address the parents’ concern about the bedwetting. It also personalizes the situation by bringing the nurse’s own children into the conversation, which is generally not recommended in professional healthcare communication.

Choice A rationale

An increasing abdominal girth in a child with a VP shunt may be indicative of malabsorption of the cerebrospinal fluid (CSF) that is being shunted to the peritoneum. This is because the VP shunt is a soft, flexible tube which is inserted into a lateral ventricle and acts as a drainpipe, to give the CSF a way to flow out of the ventricles. The tube is connected to a valve, which regulates the flow of CSF. The end of the shunt is placed within the abdominal cavity (tummy area), where the CSF will be reabsorbed. Therefore, if the CSF is not being properly absorbed in the peritoneum, it could lead to an increase in abdominal girth. This is a serious concern that needs immediate attention, hence the charge nurse should be notified.

Choice B rationale

Checking bowel sounds is a common nursing intervention for assessing gastrointestinal function. However, in the context of a child with a VP shunt and increasing abdominal girth, it is less likely to be directly related to the issue at hand. While bowel sounds can provide information about the functioning of the digestive system, they do not provide direct information about the functioning of the VP shunt or the absorption of CSF in the peritoneum.

Choice C rationale

Recording retention of feeding could be relevant in cases where there are concerns about the child’s nutritional status or digestive function. However, in this case, the primary concern is related to the functioning of the VP shunt and the absorption of CSF in the peritoneum. Therefore, while it’s always important to monitor feeding in a child, it is not the most appropriate response in this specific situation.

Choice D rationale

Elevating the child’s head is often done to reduce intracranial pressure, especially in patients with conditions affecting the brain or spinal cord. However, in the context of a child with a VP shunt and increasing abdominal girth, elevating the head would not address the underlying issue of potential malabsorption of CSF in the peritoneum.