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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?

A.

Low-pitched cry

B.

Positive Babinski reflex

C.

Insomnia

D.

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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Related Questions

Correct Answer is B

Explanation

A. Gently reinsert the tubes. Tympanostomy tubes should not be reinserted by the parent. Inserting the tubes requires medical expertise and should be performed by a healthcare professional to avoid damaging the ear.

B. Call the health care clinic to report that the tubes have fallen out. This is the correct action. The healthcare provider needs to be informed to assess if new tubes are necessary. Tubes may naturally fall out as part of the healing process, but professional evaluation is essential to determine the next steps.

C. Reassure the mother that the tubes will not fall out. It is incorrect to reassure the parent that the tubes will not fall out. Tubes can fall out naturally as the eardrum heals, and parents should be prepared for this possibility and know the appropriate steps to take.

D. Take the child to an emergency department. This is generally not necessary unless there are signs of complications such as severe pain, infection, or significant hearing loss. Routine follow-up at the clinic is sufficient for a non-emergency situation like a tube falling out.

Correct Answer is D

Explanation

A. New onset of seizure disorder in the child's sibling: This does not contraindicate DTaP vaccination unless the child itself has a history of seizures or neurological disorders.

B. Evidence of sensitivity to egg antigens: DTaP vaccine is not contraindicated by egg allergy; this is more relevant to influenza vaccines.

C. Afebrile otitis media: This is not a contraindication for DTaP vaccination.

D. Temperature of 40.5° C (104.9° F) after last DTaP: A high fever following a previous dose of DTaP may indicate a severe reaction, necessitating caution or further evaluation before administering another dose.

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