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 C
Explanation
A. "I know that my child will need to have a companion when swimming." This is a correct precaution to prevent drowning in case of a seizure.
B. "I will make my child wear a medical identification bracelet." This is correct to alert others in case of an emergency.
C. "I will need to give antiseizure medications when my child has a seizure." Antiseizure medications are typically administered as a preventive measure, not during a seizure. Emergency medications (e.g., rectal diazepam) may be used for prolonged seizures but are not routine for every seizure.
D. "I will have my child wear a bike helmet when riding a bike or skateboard." This is correct to protect the child from head injuries during activities.
Correct Answer is A
Explanation
A. 2 to 3 weeks: The incubation period for varicella is typically 10 to 21 days, or 2 to 3 weeks.
B. 7 to 10 days: This is shorter than the actual incubation period for varicella.
C. 3 to 4 weeks: This exceeds the typical maximum incubation period of 21 days.
D. 2 to 5 days: This is significantly shorter than the typical incubation period for varicella.