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 B
Explanation
A. Restrain the toddler for 1 hr after the procedure: Restraint is not appropriate post-procedure. The child should be monitored for complications but not physically restrained unless medically necessary.
B. Place the toddler in a side-lying, knee-chest position: This position flexes the spine and opens the spaces between the vertebrae, allowing for easier access to the subarachnoid space for the lumbar puncture.
C. Ask another nurse to assist with holding the toddler in a prone position: The prone position is incorrect for lumbar punctures. The side-lying, knee-chest position is standard.
D. Swaddle the toddler in a warm blanket: Swaddling may comfort the toddler but does not facilitate the lumbar puncture.
Correct Answer is B
Explanation
A. Apply oxygen by nasal cannula: Applying oxygen can be beneficial but is not the immediate priority during an active seizure. Protecting the airway comes first.
B. Turn the client to a lateral position: This action prevents aspiration by keeping the airway clear if the client vomits or has excessive secretions.
C. Administer an anticonvulsant medication: Medications may be necessary later, but immediate safety and airway protection take precedence.
D. Check the client’s oxygen saturation: Monitoring oxygen saturation is important but should follow positioning to ensure airway protection.