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.
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.
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