The nurse is educating parents of a child with a cleft palate.
What should the nurse instruct the parents to report immediately?

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.

Choice A rationale

The carotid pulse is not the most reliable location to check an infant’s pulse because it can be difficult to locate and can cause discomfort to the infant.

Choice B rationale

The dorsalis pedis pulse is not the most reliable location to check an infant’s pulse because it can be difficult to locate in small infants.

Choice C rationale

The temporal pulse is not the most reliable location to check an infant’s pulse because it can be affected by external factors such as temperature and can be difficult to locate in small infants.

Choice D rationale

The apical pulse is the most reliable location to check an infant’s pulse. It is located at the apex of the heart and can be easily heard using a stethoscope. It provides the most accurate assessment of the heart rate.