A nurse is collecting data from a 4-month-old infant who has meningitis. Which of the following manifestations should the nurse expect?
Constipation
Depressed anterior fontanel
Presence of the rooting reflex
High-pitched cry
The Correct Answer is D
D. A high-pitched cry, often described as a "crying in pain" or "irritable cry," can be a characteristic sign of meningitis in infants. The cry may sound different from the infant's usual cry and may be associated with irritability, discomfort, or pain. It can be indicative of increased intracranial pressure and neurological irritation caused by the inflammation of the meninges.
A. Constipation is not typically associated with meningitis in infants. Meningitis is an inflammation of the membranes surrounding the brain and spinal cord, which can cause symptoms such as fever, irritability, poor feeding, vomiting, and lethargy.
B. A depressed anterior fontanel (sunken soft spot on the baby's head) is not a typical manifestation of meningitis. Meningitis may cause signs of increased intracranial pressure, such as a bulging fontanel, rather than a depressed fontanel.
C. he presence of the rooting reflex is not specific to meningitis. The rooting reflex is a normal reflex present in infants, where they turn their head toward a stimulus (such as stroking the cheek or corner of the mouth) in search of nourishment (typically the breast or bottle).
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Related Questions
Correct Answer is A
Explanation
A. Rheumatic fever often develops as a complication of untreated or inadequately treated streptococcal throat infections, particularly group A Streptococcus. A history of a recent sore throat in a family member could suggest a streptococcal infection, which is a risk factor for developing rheumatic fever.
B. Chickenpox is caused by the varicella-zoster virus and is not directly related to rheumatic fever. While viral infections can trigger or exacerbate rheumatic fever in susceptible individuals, chickenpox itself is not a significant risk factor for rheumatic fever.
C. Fifth disease, also known as erythema infectiosum, is caused by parvovirus B19 and is not associated with rheumatic fever. Fifth disease primarily affects the skin, causing a characteristic rash, and is typically a mild illness in children.
D. Gastritis, inflammation of the stomach lining, is not directly related to rheumatic fever. While some gastrointestinal conditions may be associated with autoimmune disorders, gastritis itself is not a known risk factor for rheumatic fever.
Correct Answer is D
Explanation
D. Place resuscitation equipment at the child's bedside. This is because epiglottitis can lead to a life- threatening emergency requiring immediate intervention, and having resuscitation equipment readily available is essential for rapid response.
A. Establishing intravenous access may be necessary for administering fluids and medications but it is not the nurse's priority action when caring for a child with suspected epiglottitis.
B. Droplet precautions help reduce the risk of transmission of respiratory pathogens to others. However, the priority is to address the child's respiratory distress and potential airway compromise.
C. Providing blow-by humidified oxygen can be beneficial in managing the child's respiratory status. However, securing the airway takes precedence over other interventions, as indicated by the guidelines for managing epiglottitis.
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