A nurse is assessing a toddler who is toilet-trained and has a temperature of 38.5° C (101.3° F). Which of the following findings should the nurse recognize as an indication of a urinary tract infection (UTI)?

A. Depressed scalp veins: This is an incorrect choice. In hydrocephalus, there is increased pressure within the skull due to the accumulation of cerebrospinal fluid (CSF). This increased pressure typically leads to distended scalp veins rather than depressed ones.

B. Sunken anterior fontanels: This is an incorrect choice. The fontanel, also known as the soft spot on an infant's head, may actually bulge rather than appear sunken in cases of hydrocephalus due to increased intracranial pressure.

C.Bulging eyes:In individuals with hydrocephalus, especially infants and young children, bulging eyes can sometimes occur.The increased pressure inside the skull can affect various structures within the brain, including the optic nerve and the muscles that control eye movement. This can lead to a condition called papilledema, where the optic nerve becomes swollen due to the pressure. Papilledema can cause changes in vision and, in some cases, contribute to the appearance of bulging eyes.

D.Separated cranial sutures:The separation of cranial sutures in hydrocephalus occurs due to the increased pressure from the excess CSF. This pressure can cause the bones of the skull to move apart, leading to visible gaps or widening of the sutures. Clinically, this can be observed through imaging studies such as CT scans or MRI.

A. The infant does not exhibit fear of strangers.

The infant does not exhibit fear of strangers is not a finding that the nurse should report to the provider, as this is a normal social behavior for a 6-month-old infant. Infants usually develop stranger anxiety between 8 and 12 months of age, when they become more aware of their surroundings and attachment figures.

B. The infant does not roll over from his abdomen to his back.

By 6 months of age, most infants can roll over in both directions— from their abdomen to their back and vice versa. The inability to roll over from abdomen to back may indicate a delay in gross motor skills development. This finding should be reported to the healthcare provider for further evaluation.

C. The infant does not pick up objects from the floor with his fingers.

By 6 months of age, infants typically begin to develop the ability to grasp and pick up objects using their fingers. This milestone is part of fine motor skills development. The inability to pick up objects from the floor with fingers may indicate a delay in fine motor skills and should be reported to the provider for further assessment.

D. The infant does not sit on the floor unsupported.

By 6 months of age, infants typically begin to develop the ability to sit unsupported for short periods. While some variability exists in when infants achieve this milestone, the inability to sit unsupported at 6 months may indicate a delay in gross motor skills development. This finding should be reported to the provider for further evaluation.