Tanner Stages can be used to help determine an adolescent's stage of puberty. You have a 13-year-old female patient. What information does the nurse need to collect in order to use this scale for puberty determination? (Select All that Apply.)

A. Encouraging the child to drink fluids to stay hydrated is incorrect because while hydration is important, the priority is identifying and managing potential increased intracranial pressure (ICP). Giving fluids before assessing neurological status may delay recognition of a serious complication.

B. Positioning the child in a flat supine position is incorrect because a flat supine position can actually increase ICP. Postoperative positioning for brain surgery typically involves head elevation (30 degrees) to promote venous drainage and reduce ICP, unless contraindicated.

C. Administering an antiemetic to control vomiting is incorrect as controlling vomiting is secondary. Vomiting can be a sign of increased ICP, so addressing the underlying cause is more important than treating symptoms alone.

D. Assessing the child's neurological status and checking for signs of increased intracranial pressure is correct. Vomiting and headache after brain surgery are red flags for increased ICP, which can lead to life-threatening complications such as brain herniation. Priority nursing actions include frequent neurological assessments (level of consciousness, pupil size and reactivity, motor function), monitoring vital signs for changes in blood pressure, pulse, and respiration (Cushing’s triad), notifying the healthcare provider immediately if ICP is suspected, and implementing interventions to reduce ICP, such as proper positioning, oxygenation, and minimizing stimuli.

A. Limiting family involvement to scheduled visiting hours is incorrect because family-centered care promotes unrestricted or flexible family presence. Restricting involvement contradicts the idea that the family plays a continuous and central role in the child’s life.

B. Encouraging the family to follow unit routines without modification is incorrect because family-centered care values collaboration and flexibility. Care should be adapted to meet the needs of the child and family, not force the family to conform to rigid hospital routines.

C. Assuming the healthcare team is the primary source of support for the child is incorrect because, in family-centered care, the family—not the healthcare team—is recognized as the primary and constant source of support, comfort, and advocacy for the child.

D. Involving the family in care planning and decision-making for the child is correct because it acknowledges that the family is the constant in the child’s life. This approach respects the family’s knowledge of the child, promotes collaboration, and supports continuity of care across healthcare settings.