A 6-month-old infant with a ventricular shunt presents with irritability, vomiting, and a bulging fontanel.
The nurse suspects:

Choice A rationale

During a tonic-clonic seizure, loss of consciousness and uncontrolled muscle movements carry a high risk of aspiration if the child vomits or has excessive oral secretions. Turning the child to the side (recovery position) allows gravity to drain secretions and prevents the tongue from obstructing the posterior pharynx, which is the most critical immediate safety intervention.

Choice B rationale

While benzodiazepines (like rectal or intranasal diazepam or midazolam) are used to stop seizures, this is done via a non-oral route as the child is typically unconscious and unable to safely swallow during a seizure, posing a severe aspiration risk. Oral administration is contraindicated during the acute seizure event itself.

Choice C rationale

Inserting a tongue blade or any object into the mouth during a seizure is strictly contraindicated. The child's jaw may clamp down forcefully, causing injury to the child's teeth, gums, or jaw, or causing the object to break and obstruct the airway, leading to far more harm than benefit.

Choice D rationale

Restraining the child during a seizure is inappropriate and dangerous. The forceful muscle contractions can cause injury (fractures or dislocations) if movement is restricted against the convulsive forces. The nurse's role is to clear the area and protect the head and limbs from striking hard objects.

Choice A rationale

Photophobia, or an extreme sensitivity to light, is a common symptom in meningitis, resulting from the meningeal irritation and inflammation caused by the bacterial infection. The meninges, the protective layers covering the brain and spinal cord, contain pain-sensitive fibers. When inflammation reaches the optic nerve pathways or specific cranial nerves, light perception becomes a painful stimulus.

Choice B rationale

A petechial or purpuric rash is a critical and potentially ominous finding, especially in meningococcemia (caused by Neisseria meningitidis). The rash is caused by endothelial damage and vasculitis as the bacteria and inflammatory mediators enter the bloodstream, leading to small, non-blanching hemorrhages beneath the skin due to capillary leakage and microthrombi formation.

Choice C rationale

Nuchal rigidity (stiffness of the neck), a classic sign, is caused by inflammation of the meninges surrounding the cervical spinal cord. Attempting to flex the neck stretches the irritated meninges, eliciting pain and muscle spasm. This rigidity is often assessed using maneuvers like Brudzinski's or Kernig's signs, indicating meningeal irritation.

Choice D rationale

A high-pitched cry is more commonly associated with increased intracranial pressure (ICP), which can be a complication of severe meningitis, particularly in infants due to hydrocephalus or cerebral edema. While a sign of neurological distress, it is a less direct or specific initial symptom compared to the direct signs of meningeal irritation or systemic infection.

Choice E rationale

Seizures are a frequent complication, particularly in infants and young children with bacterial meningitis. They result from the direct inflammatory irritation of the cerebral cortex by the infectious process, cerebral edema, or vascular changes (e.g., thrombosis, infarcts) associated with severe intracranial infection, causing abnormal electrical activity.