The nurse is providing instructions to the parents of an infant with a ventriculoperitoneal shunt. The nurse includes which of the following instructions?
1. Call the physician if the infant is fussy.
2. Expect an increased urine output from the shunt.
3. Call the physician if the infant has a high-pitched cry.
4. Position the infant on the side of the shunt when the infant is put to bed.
3
Rationale: If the shunt is malfunctioning, the fluid from the ventricle part of the brain will not be diverted to the peritoneal cavity. The cerebrospinal fluid will build up in the cranial area. The result is increased intracranial pressure, which then causes a high-pitched cry in the infant. The infant should not be positioned on the side of the shunt because this will cause pressure on the shunt and skin breakdown. This type of shunt affects the gastrointestinal system, not the genitou-rinary system, and an increased urinary output is not expected. "Call the physician if the infant is fussy" is a concern only if other signs indicative of a complication are occurring.
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