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. 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.
Correct Answer is D
Explanation
A. Haemophilus Influenza Type B (HIB) Vaccine and TDAP. HIB vaccine reduces the incidence of meningitis caused by Haemophilus influenzae, but TDAP does not target pathogens responsible for meningitis.
B. Inactivated polio vaccine (IPV) and Pneumococcal Conjugate Vaccine (PCV). IPV prevents polio but has no impact on meningitis incidence. PCV is correct for preventing Streptococcus pneumoniae meningitis.
C. DTAP and Varicella Vaccine. DTAP does not prevent bacterial meningitis, and varicella vaccine prevents chickenpox, not meningitis.
D. Pneumococcal Conjugate Vaccine (PCV) and Haemophilus Type B (HIB Vaccine). These vaccines directly prevent bacterial meningitis caused by Streptococcus pneumoniae and Haemophilus influenzae, which were previously leading causes of meningitis in children.