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. The parent reports the child will not keep the arm elevated on the pillow: Not a priority. While elevation is important, it is not immediately concerning.

B. The fingers on the right hand have a capillary refill of 4 seconds: Correct. A capillary refill time of more than 2 seconds indicates poor perfusion, which can be a sign of compartment syndrome, a serious complication.

C. The fingertips of the right hand are swollen and bruised: Concerning, but swelling and bruising can be normal post-injury. Immediate concern is perfusion.

D. The child is not attempting to move her right arm or fingers: Concerning, but can be due to pain or fear. Poor perfusion (B) is a more immediate threat.

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.