The nurse is measuring the frontal occipital circumference (FOC) of a 3-months old infant, and notes that the FOC has increased 5 inches since birth and the child's head appears large in relation to body size. Which action is most important for the nurse to take next?

Correct Answer: B

Rationale: The correct answer is B) Palpate the anterior fontanel for tension and bulging. In a 3-month-old infant with a significant increase in frontal occipital circumference (FOC) and a large head-to-body size ratio, assessing the anterior fontanel is crucial to evaluate for signs of increased intracranial pressure. A tense or bulging fontanel could indicate abnormal brain growth or hydrocephalus, a serious condition requiring immediate medical attention. Option A) Measure the infant's head-to-toe length is not the most important action in this scenario as the concern is primarily related to the head circumference and signs of increased intracranial pressure, not overall body length. Option C) Observing the infant for sunken eyes is unrelated to the assessment of a large head size and would not provide relevant information in this situation. Option D) Plotting the measurement on the infant's growth chart is not the most immediate action needed when there are concerns about abnormal head growth and potential signs of increased intracranial pressure. It is important to address acute clinical signs first before considering long-term growth patterns. In a pediatric nursing context, understanding the significance of abnormal head growth and recognizing signs of increased intracranial pressure is critical for early detection and intervention in conditions like hydrocephalus. This scenario highlights the importance of thorough assessment skills and prompt action in pediatric care to ensure the well-being of infants.

Correct Answer: B

Rationale: Notifying the healthcare provider is crucial when an infant scheduled for intussusception reduction passes a soft-formed brown stool as it may indicate spontaneous reduction of the intussusception. The healthcare provider needs to be informed to assess if the procedure is still necessary or if further evaluation is required.

Correct Answer: A

Rationale: The correct answer is A) Describe the side-lying, knees-to-chest position that must be assumed during the procedure. This is the most appropriate response because it provides essential information to prepare the child for the lumbar puncture procedure. By describing the position the child needs to be in, the nurse ensures the child understands what to expect and can cooperate better during the procedure. Option B) Explain that fluids cannot be taken for 8 hours before the procedure and for 4 hours after the procedure is incorrect because it does not address the child's immediate concerns about the procedure itself. This information is important but not as crucial as preparing the child for the procedure itself. Option C) Reassuring the child that there will be no restrictions on activity after the procedure is completed is incorrect as it does not address the child's anxiety or provide information about the procedure. Option D) Telling the child to expect loud clicking noises during the procedure that may be slightly annoying is incorrect as it may increase the child's anxiety without providing useful information to help the child cope during the procedure. Educationally, when preparing a child for a medical procedure, it is crucial to provide clear, age-appropriate information to reduce anxiety and facilitate cooperation. Describing the procedure in a simple and understandable way helps build trust between the child and healthcare provider, leading to a more positive experience for the child.

Correct Answer: D

Rationale: The priority action for the nurse is to review the immunization documentation of the child with HIV to ensure they have received the necessary vaccines. This step is crucial in protecting the child's health and preventing further complications from vaccine-preventable diseases like pertussis. It is important to verify the child's immunization status before considering other interventions.

Correct Answer: D

Rationale: The best response for the nurse in this situation is to help the child understand that the separation is temporary. Waving bye-bye to mommy can be reassuring to the child and make the separation process easier. It acknowledges the child's feelings while providing a positive and comforting interaction.