Which of the following steps is correct when measuring head circumference in an infant?

Choice A rationale

Calculating the safe dosage is a crucial step in administering medication to a toddler. This ensures that the child receives the appropriate amount of medication based on their weight and age.

Choice B rationale

Identifying the toddler by asking the caregiver is an important step to ensure that the correct medication is given to the correct child.

Choice C rationale

Telling the caregiver to administer the medication is not recommended. As a nurse, it is your responsibility to administer the medication to ensure it is done correctly.

Choice D rationale

Offering juice after the medication can help mask any unpleasant taste and make the medication administration process more tolerable for the toddler.

Choice E rationale

Asking the toddler to pick a toy to hold during administration can serve as a distraction and make the process less stressful for the child.

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.