A nurse is assessing a five-month-old Infant. The nurse should recognize that which of the following manifestations is associated with a central nervous system (CNS) Infection?

Oliguria

Negative Kernig's sign

Bulging fontanel

Negative Brudzinski sign

Answer and Explanation

The Correct Answer is C

A.   Oliguria (decreased urine output) may be a sign of dehydration or kidney dysfunction but is not typically the primary symptom of a CNS infection.
B.   A negative Kernig's sign (no resistance to leg extension) is a reassuring sign and suggests that meningitis or other CNS infections are less likely. A positive sign would suggest possible meningitis.
C.   Bulging of the fontanel is a sign of increased intracranial pressure, which can occur in CNS infections such as meningitis. This is a critical finding that requires immediate attention.
D.   A negative Brudzinski sign means there is no neck stiffness or pain when the neck is flexed, which is a good finding. A positive sign would suggest the presence of meningitis.

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Correct Answer is C

Explanation

A. Avoiding oral feedings may not be necessary unless there are specific complications. The focus should be on preventing aspiration, but not necessarily withholding feedings.
B. Direct pressure should not be applied to the surgical site unless directed by a provider, as this could cause further complications.
C. Frequent diaper changes and keeping the incision site clean and dry is essential to prevent infection and protect the surgical site.
D. The infant should be positioned according to the provider's orders to avoid pressure on the surgical site and spinal cord, but lying flat may not always be necessary.

A. Elevating the legs on a pillow B. Applying heat therapy to the casted area C. Removing the casts periodically for bathing D. Encouraging the infant to crawl and bear weight on the affected leg

Correct Answer is A

Explanation

A. Elevating the legs on a pillow helps reduce swelling and discomfort while the cast is healing.
B. Heat therapy should not be applied to the casted area, as it could cause skin irritation or burns.
C. Casts should not be removed for bathing unless specifically ordered by the provider.
D. Encouraging the infant to crawl or bear weight on the affected leg is not appropriate until the cast is removed and healing is complete.

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A nurse is assessing a five-month-old Infant. The nurse should recognize that which of the following manifestations is associated with a central nervous system (CNS) Infection?

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