The nurse is caring for a child who has had a ventriculoperitoneal shunt (VP) for hydrocephalus and observes an increasing abdominal girth.
What is the most appropriate response?
Notify the charge nurse of possible malabsorption.
Check bowel sounds.
Record retention of feeding.
Elevate the child’s head.
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Soft and flat fontanels are normal in healthy infants. In hydrocephalus, increased intracranial pressure causes bulging fontanels due to excess cerebrospinal fluid accumulation.
Choice B rationale: Proteinuria is a renal finding and not associated with hydrocephalus. Hydrocephalus affects the central nervous system, not kidney filtration or protein excretion.
Choice C rationale: Dilated scalp veins occur due to elevated intracranial pressure from cerebrospinal fluid buildup. Venous distension is a visible sign in infants with hydrocephalus.
Choice D rationale: Hypertension is not a typical sign of hydrocephalus in infants. The condition primarily presents with neurological and cranial changes, not systemic blood pressure elevation.
Correct Answer is B
Explanation
Choice A rationale
While assistance may be needed to comfort the toddler during the procedure, holding the toddler in a prone position is not the recommended position for a lumbar puncture.
Choice B rationale
Placing the toddler in a side-lying, knee-chest position is the correct position for a lumbar puncture. This position helps to open up the spaces between the vertebrae, making it easier to access the spinal canal.
Choice C rationale
Restraining the toddler for 1 hour after the procedure is not necessary and could cause distress to the toddler.
Choice D rationale
While swaddling the toddler in a warm blanket may provide comfort, it is not a necessary step in the administration of a lumbar puncture.
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