The nurse is monitoring a 7-year-old child post-surgical resection of a supratentorial (cerebral) brain tumor. Which vital sign finding indicates Cushing's triad?

A. Placing the client on their side is the correct action to prevent aspiration and help keep the airway open during a seizure. It also helps drain secretions and can reduce the risk of choking.

B. Holding the client's arms and legs is not recommended during a seizure because this can lead to injury to the client and the nurse. Seizure activity should be allowed to run its course in a safe environment.

C. Placing the client back in bed during a seizure could be dangerous, as it is better to keep the client safe on the floor to prevent falling or injury. The priority is ensuring the client’s safety during the seizure rather than moving them back into bed.

D. Inserting a tongue blade in the client's mouth is an outdated practice and can lead to injury or even cause the client to bite down on the tongue blade. There is no need to insert anything into the mouth during a seizure.

A. While alterations in pupil size and reactivity are signs of increased ICP, increased motor response is not a late sign and typically reflects an early sign of brain dysfunction.

B. Extension or flexion posturing may occur with increased ICP, but weight gain is not a sign of ICP.

C. Tachycardia can occur early in ICP, but it does not typically present as a late sign. Altered pupil size and reactivity may occur, but these are not exclusive to late ICP signs.

D. This is the correct answer. Cheyne-Stokes respirations, which are characterized by alternating periods of apnea and deep breathing, are a late sign of increased ICP in infants. Additionally, changes in pupil size (such as dilated or non-reactive pupils) are a late indicator of increasing intracranial pressure.