A nurse is collecting data from a 5-month-old infant who has increased intracranial pressure (ICP) resulting from hydrocephalus. Which of the following manifestations should the nurse expect?

Low-pitched cry

Positive Babinski reflex

Insomnia

Bulging fontanel

Answer and Explanation

The Correct Answer is D

A. Low-pitched cry: A high-pitched cry, not a low-pitched one, is more typical of increased ICP in infants. A low-pitched cry is not a common sign of ICP and may be more related to other conditions.

B. Positive Babinski reflex: The Babinski reflex is normal in infants up to about 1 year of age and is not indicative of increased ICP. It is a normal finding and not specific to increased intracranial pressure.

C. Insomnia: Infants with increased ICP may exhibit irritability and changes in sleeping patterns, but insomnia (difficulty sleeping) is not a classic symptom. The focus should be on other more specific signs like changes in cry and physical appearance.

D. Bulging fontanel: A bulging fontanel is a key sign of increased ICP in infants. It occurs due to pressure within the skull causing the soft spot on the head to protrude. This is a classic symptom of increased intracranial pressure in infants.

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Correct Answer is C

Explanation

A. Attempt to obtain a throat culture: This is contraindicated because manipulating the throat could exacerbate airway obstruction, leading to a potential respiratory emergency.

B. Use a tongue depressor to observe the back of the throat: This can provoke a spasm or cause complete airway obstruction in a child with epiglottitis and should be avoided.

C. Apply humidified oxygen via a mask: This helps to keep the airways moist and can provide some relief and improve oxygenation while minimizing the risk of airway manipulation.

D. Initiate airborne precautions: Epiglottitis primarily requires droplet precautions, not airborne. Airborne precautions are used for diseases like tuberculosis, which are spread through smaller droplets that remain suspended in the air.

A. Rotavirus B. Measles, mumps, rubella (MMR) C. Varicella (VAR) D. Influenza

Correct Answer is A

Explanation

A. Rotavirus: The rotavirus vaccine is recommended for infants at 2, 4, and possibly 6 months of age, depending on the vaccine formulation. It helps protect against rotavirus, which can cause severe diarrhea and dehydration in infants.

B. Measles, mumps, rubella (MMR): The MMR vaccine is not given until 12-15 months of age. It is not part of the vaccination schedule for a 4-month-old infant.

C. Varicella (VAR): The varicella vaccine is typically administered at 12-15 months of age. It is not appropriate for a 4-month-old infant.

D. Influenza: The influenza vaccine is recommended annually starting at 6 months of age. A 4-month-old is too young to receive the influenza vaccine.

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