A nurse is assessing a 2-month-old infant with a patent ductus arteriosus.
Which finding is most concerning?

Choice A rationale

Administering sedation (e.g., narcotics or benzodiazepines) prior to invasive procedures like suctioning is crucial to blunt the reflex sympathetic response. Suctioning can induce coughing, gagging, and pain, which dramatically increase systemic blood pressure and, consequently, cerebral blood volume and intracranial pressure (ICP), leading to secondary brain injury. Sedation provides analgesia and anxiolysis, minimizing these adverse physiological reactions.

Choice B rationale

Lowering the head of the bed (HOB) can increase cerebral blood flow and impede venous drainage from the head and neck vessels, thereby increasing cerebral blood volume and consequently intracranial pressure (ICP). For a child with severe traumatic brain injury, the HOB should typically be elevated to 30 degrees to promote optimal venous outflow and pressure regulation.

Choice C rationale

While performing suctioning quickly minimizes the duration of the noxious stimulus, it does not address the initial reflexive physiological response to the stimulus itself, which triggers the rise in ICP. The most effective preventative measure is to pre-oxygenate and administer sedation to mitigate the body's adverse reaction before and during the necessary procedure.

Choice D rationale

Delaying suctioning until ICP has already risen is a reactive measure, not a preventative one, and risks secondary brain injury from sustained or high-peak ICP. Suctioning must be performed when secretions compromise airway patency, but the goal is to mitigate the expected ICP rise through proactive interventions like pre-sedation and hyperoxygenation before the procedure is initiated.

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.