A nurse is collecting data from an 8-month-old infant who has increased intracranial pressure (ICP). Which of the following manifestations should the nurse expect?
Insomnia
Positive Babinski reflex
Bulging fontanel
Low-pitched cry
The Correct Answer is C
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.
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Correct Answer is D
Explanation
A. "I cannot wash my child's hair prior to the procedure.": Hair should be clean and free of oils or products to ensure proper electrode placement and signal conduction.
B. "This procedure will be painful for my child.": An EEG is a non-invasive and painless test.
C. "I should not give my child anything to eat prior to the procedure.": Eating is usually permitted before an EEG unless sedation is planned.
D. "My child should remain quiet and still during this procedure.": Movement can interfere with the test's accuracy, so the child needs to stay calm and still during the procedure.
Correct Answer is B
Explanation
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.