A 6-week-old baby is brought to the clinic for a follow-up visit ...

[Yolanda]

A 6-week-old baby is brought to the clinic for a follow-up visit after having surgical repair of a myelomeningocele. His head circumference was 33 cm (12 inches) at birth. Now the nurse assesses his head circumference at 36 cm (14.1 inches).
 
  What action by the nurse is most appropriate?
  A.
  Assess the child for signs of hydrocephalus.
  B.
  Document the measurement in the child's chart.
  C.
  Educate the parents on possible shunt placement.
  D.
  Inquire about signs of increased intracranial pressure.

Question 2

A new nurse is caring for a child who had a ventriculoperitonea l shunt placed 2 days ago for hydrocephalus. Which action by the new nurse causes the experienced nurse to intervene?
 
  A.
  Administers IV antibiotics
  B.
  Asks for medication to treat nausea
  C.
  Palpates the shunt tract with assessments
  D.
  Raises the head of the bed to 30

[mmj22343]

Answer to Question 1

ANS: B
Increasing head circumference is a sign of possible hydrocephalus. The average head circumference of an infant at birth is 33-38 cm (12-14 inches) and increases by 2 cm/month (0.75 inches/month). This child's head circumference is normal and the nurse should document the information; no other actions are needed.

Answer to Question 2

ANS: B
Peritonitis is a complication of this procedure and manifestations of this include rebound tenderness, abdominal muscle rigidity, nausea, and vomiting. The new nurse should conduct a more thorough abdominal assessment instead of asking for anti-nausea medication. The other actions are appropriate and do not require the experienced nurse to intervene.

[Yolanda]

Excellent

[TheDev123]

Gracias!