The nurse is monitoring an infant for signs of increased ...

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The nurse is monitoring an infant for signs of increased intracranial pressure (ICP). Which are late signs of increased ICP in an infant (Select all that apply)?
 
  a. Tachycardia
  b. Alteration in pupil size and reactivity
  c. Increased motor response
  d. Extension or flexion posturing
  e. Cheyne-Stokes respirations

Question 2

The nurse is caring for a neonate with suspected meningitis. Which clinical manifestations should the nurse prepare to assess if meningitis is confirmed (Select all that apply)?
 
  a. Headache
  b. Photophobia
  c. Bulging anterior fontanel
  d. Weak cry
  e. Poor muscle tone

[EAN94]

Answer to Question 1

ANS: B, D, E
Late signs of ICP in an infant or child include bradycardia, alteration in pupil size and reactivity, decreased motor response, extension or flexion posturing, and Cheyne-Stokes respirations.

Answer to Question 2

ANS: C, D, E
Assessment findings in a neonate with meningitis include bulging anterior fontanel, weak cry, and poor muscle tone. Headache and photophobia are signs seen in an older child.

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Thank you

[EAN94]

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