The nurse observes a mother administering ferrous sulfate (iron drops) to her 11-month-old child, followed by 2 ounces (60 mL) of orange juice.

What should be the nurse’s subsequent action?

The correct answer is: C

Choice A reason: Comparing the child’s vital signs over the past three weeks could provide data on any changes in his physical health status. However, without additional context, this information alone may not be sufficient to determine the cause of his symptoms. Vital signs are typically within the following ranges for a healthy 10-year-old: temperature 97.8°F to 99.1°F (36.5°C to 37.3°C), pulse 70 to 110 beats per minute, respirations 17 to 22 breaths per minute, and blood pressure 90/60 mmHg to 120/80 mmHg.

Choice B reason: Counseling the parents to pay more attention to the child might be helpful if the child’s symptoms are due to emotional neglect or lack of parental involvement. However, this intervention assumes that the parents are not attentive without evidence and does not directly address the child’s reported symptoms.

Choice C reason: Asking the boy to describe a typical day at school is a non-invasive way to gather more information about potential stressors or issues that could be contributing to his symptoms. This approach can help identify if the symptoms are related to school environment, bullying, academic pressure, or other psychosocial factors.

Choice D reason: Conducting a complete neurological assessment would be appropriate if there were specific indications of neurological issues. Since the boy’s symptoms are non-specific and could be related to a variety of causes, including stress or anxiety, a neurological assessment might not be the most immediate step without further evidence suggesting a neurological cause.

Choice B rationale
The absence of continuous headaches in the child indicates that the VP shunt is functioning normally. A VP shunt is used to treat hydrocephalus by draining excess cerebrospinal fluid from the brain to the abdomen. If the shunt is functioning properly, it should relieve pressure on the brain and reduce symptoms such as headaches.
Choice A rationale
While growth in height could be a positive sign of overall health and development, it does not specifically indicate that a VP shunt is functioning properly.
Choice C rationale
The presence of an intracranial pressure (ICP) monitoring probe does not indicate whether the shunt is functioning properly. The probe is a device used to measure ICP and does not provide information about the functionality of the shunt.
Choice D rationale
Being afebrile with normal vital signs postoperatively is a positive sign, but it does not specifically indicate that the shunt is functioning properly.