A 4-month-old with hydrocephalus is admitted to the hospital for shunt revision. When assessing for increased intracranial pressure, the nurse should observe the child for which finding(s)? Select all that apply.

A. IV site without redness or swelling: The IV site appears normal with no signs of infiltration or infection, so no immediate follow-up is required. This finding indicates proper IV insertion and maintenance.

B. Temperature: 98.8° F (37.1° C): This is within normal limits and does not indicate fever or infection, so it does not require immediate follow-up.

C. Respirations: 28 breaths/minute: This is above the normal adult range (12–20 breaths/minute) and may indicate respiratory distress due to pain, shallow breathing, or possible pulmonary complications such as atelectasis or pneumonia, requiring close monitoring and follow-up.

D. Heart rate: 92 beats/minute: Slightly elevated but within mild tachycardia range, which could be related to pain or anxiety. It should be monitored but does not require urgent follow-up.

E. Taking shallow breaths: Shallow breathing is concerning in a client with rib fractures, as it increases the risk for hypoventilation, atelectasis, and pneumonia. This requires immediate intervention, such as pain management and respiratory support.

F. Alert and oriented to person, place, time, and situation: Cognitive status is normal, so no follow-up is needed.

G. Pain 8 on a 0 to 10 scale: Severe pain limits deep breathing and mobility, increasing the risk of complications. Pain management should be addressed promptly to improve comfort and respiratory function.

H. Blood pressure: 138/82 mm Hg: Slightly elevated, likely related to pain or stress. Monitor trends, but it does not require immediate follow-up at this time.

A. Ask the client about gastrointestinal pain: PPIs reduce gastric acid secretion, which relieves symptoms such as heartburn, epigastric pain, and discomfort related to peptic ulcer disease or GERD. Assessing the client’s report of pain evaluates whether the medication is effective.

B. Auscultate for bowel sounds in all quadrants: Bowel sounds indicate gastrointestinal motility rather than acid suppression. PPIs do not directly affect peristalsis, so auscultation is not a reliable measure of drug effectiveness.

C. Measure the client's fluid intake and output: Fluid balance is important in overall patient care but is not a direct indicator of how well a PPI is working. Intake and output monitoring is more relevant to renal or fluid management.

D. Monitor the client's serum electrolyte levels: Electrolyte monitoring may be necessary with prolonged PPI therapy due to risks such as hypomagnesemia, but it does not provide immediate information on short-term medication effectiveness.