A 2-day-old infant with hydrocephalus returns from surgery following placement of a ventriculoperitoneal shunt. Which nursing intervention(s) should the practical nurse (PN) implement during postoperative care? (Select all that apply.)
Explanation & Rationale
A. Measure head circumference daily. - Monitoring head circumference is crucial to detect changes that might indicate increased intracranial pressure after the shunt placement. B. Document strict intake and output. - Monitoring fluid intake and output helps assess the infant's hydration status and shunt functionality. C. Irrigate shunt and pump valve every 12-hours. - Shunt irrigation should be performed by specialized healthcare professionals, not typically by a practical nurse. D. Monitor body temperature every 4 hours. - Postoperative monitoring includes assessing for signs of infection or systemic changes, which might be indicated by changes in body temperature. E. Place in Trendelenburg position. - The Trendelenburg position is not typically recommended post-ventriculoperitoneal shunt placement and should be avoided unless specifically prescribed by the healthcare provider.