The nurse is preparing to care for a newborn receiving phototherapy.
Which interventions should be included in the plan of care? Select all that apply.

Choice A rationale

An increasing abdominal girth in a child with a VP shunt may be indicative of malabsorption of the cerebrospinal fluid (CSF) that is being shunted to the peritoneum. This is because the VP shunt is a soft, flexible tube which is inserted into a lateral ventricle and acts as a drainpipe, to give the CSF a way to flow out of the ventricles. The tube is connected to a valve, which regulates the flow of CSF. The end of the shunt is placed within the abdominal cavity (tummy area), where the CSF will be reabsorbed. Therefore, if the CSF is not being properly absorbed in the peritoneum, it could lead to an increase in abdominal girth. This is a serious concern that needs immediate attention, hence the charge nurse should be notified.

Choice B rationale

Checking bowel sounds is a common nursing intervention for assessing gastrointestinal function. However, in the context of a child with a VP shunt and increasing abdominal girth, it is less likely to be directly related to the issue at hand. While bowel sounds can provide information about the functioning of the digestive system, they do not provide direct information about the functioning of the VP shunt or the absorption of CSF in the peritoneum.

Choice C rationale

Recording retention of feeding could be relevant in cases where there are concerns about the child’s nutritional status or digestive function. However, in this case, the primary concern is related to the functioning of the VP shunt and the absorption of CSF in the peritoneum. Therefore, while it’s always important to monitor feeding in a child, it is not the most appropriate response in this specific situation.

Choice D rationale

Elevating the child’s head is often done to reduce intracranial pressure, especially in patients with conditions affecting the brain or spinal cord. However, in the context of a child with a VP shunt and increasing abdominal girth, elevating the head would not address the underlying issue of potential malabsorption of CSF in the peritoneum.

Choice A rationale

Understanding the cause of illness is a complex cognitive task that typically develops later in childhood. Preschool-aged children are still developing their understanding of cause and effect, and their thinking is often more concrete than abstract.

Choice B rationale

Describing manifestations of illness is also a complex task that requires a certain level of cognitive and language development. While preschool-aged children are developing their language skills rapidly, their ability to describe complex phenomena such as the manifestations of illness is still developing.

Choice C rationale

Awareness of body functioning is a concept that typically develops later in childhood. Preschool-aged children are still learning about their bodies and how they work. Their understanding of body functioning is often concrete and based on what they can see and feel.

Choice D rationale

Relating fears to magical thinking is a characteristic of preschool-aged children’s cognitive development. At this age, children’s thinking is often dominated by fantasy and magic. They may attribute events or experiences to magical causes, and their fears may be related to these magical beliefs.