A nurse is collecting data from a 4-month old infant who has meningitis. Which of the following findings should the nurse expect?
Depressed anterior fontanel
High Pitched cry
Constipation
Presence of the rooting reflex
The Correct Answer is B
A. Depressed anterior fontanel: A depressed fontanel is typically associated with dehydration, not meningitis.
B. High-pitched cry: A high-pitched cry is a classic symptom of meningitis in infants, often associated with increased ICP.
C. Constipation: Meningitis is more likely to cause irritability and feeding difficulties than constipation.
D. Presence of the rooting reflex: The rooting reflex is normal in a 4-month-old and does not specifically indicate meningitis.
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Correct Answer is C
Explanation
A. Insomnia: Infants with increased ICP are more likely to be lethargic than to have insomnia.
B. Positive Babinski reflex: A positive Babinski reflex is normal in infants under 2 years and does not indicate ICP.
C. Bulging fontanel: A bulging fontanel is a classic sign of increased ICP due to the accumulation of fluid or swelling inside the skull.
D. Low-pitched cry: Infants with ICP typically have a high-pitched cry, not a low-pitched one.
Correct Answer is D
Explanation
A. CBC: A CBC can indicate infection (elevated white blood cell count), but it is not specific for meningitis.
B. Urinalysis: Urinalysis is not relevant for diagnosing meningitis.
C. CT scan: A CT scan can detect complications like increased intracranial pressure but does not diagnose meningitis directly.
D. Lumbar puncture: A lumbar puncture allows direct analysis of CSF for glucose, protein, white blood cells, and organisms, which is definitive for diagnosing meningitis.