A nurse is caring for a school-age child who is 1hr postoperative following a tonsillectomy. Which of the following actions should the nurse take? (Select all that apply.)

Management of increased intracranial pressure (ICP) in infants focuses on reducing cerebral swelling and preventing further neurologic damage. Because the infant skull has open sutures and fontanels, changes in intracranial pressure can often be assessed through physical examination findings. Effective treatment should result in decreased intracranial pressure, reflected by improved neurologic status and normalization of skull-related signs. Nurses monitor for indicators that suggest reduced cerebral pressure and improved brain perfusion.

Rationale:
A. Increased sleepiness may indicate worsening neurologic status rather than improvement. In infants with elevated ICP, lethargy can be a sign of decreased cerebral perfusion and progressing neurologic impairment. Therefore, increased drowsiness would not indicate treatment effectiveness.

B. Enlarged head circumference suggests ongoing or worsening intracranial pressure rather than improvement. In infants, increased ICP can lead to progressive head enlargement due to the flexibility of skull sutures. This finding would indicate ineffective treatment or disease progression.

C. Soft, flat fontanels indicate that intracranial pressure has decreased to a normal or near-normal level. When ICP is elevated, fontanels become bulging and tense due to increased cerebrospinal fluid pressure. A soft, flat fontanel is a key sign that treatment has been effective in reducing intracranial pressure.

D. Crying when disturbed is a nonspecific finding and may be normal in infants due to discomfort or environmental stimulation. Although it may indicate irritability, it is not a reliable indicator of intracranial pressure status. Effective ICP treatment is better evaluated through objective physical signs such as fontanel assessment and neurologic responsiveness.

Fall risk in pediatric clients is influenced by age, mobility, developmental stage, and conditions that affect balance, coordination, or vision. Toddlers are already at increased risk for falls because of developing motor skills, curiosity, and limited safety awareness. When a visual disturbance such as strabismus is present, depth perception and coordination may be impaired further. Nurses must identify children with the greatest fall risk to implement appropriate safety precautions and prevent injury.

Rationale:
A. An infant who has constipation is not at significant increased risk for falls because infants have limited independent mobility and are usually closely supervised. Constipation may cause discomfort or irritability, but it does not directly impair balance, vision, or ambulation. Therefore, it is not considered a major fall-risk factor.

B. A child who has asthma may require monitoring for respiratory distress, but asthma itself does not directly increase fall risk unless severe weakness or medication side effects are present. The condition mainly affects airway function rather than coordination or balance. Without additional complications, asthma is not the highest fall-risk diagnosis.

C. An adolescent who has neutropenia is at increased risk for infection rather than falls. Neutropenia reflects low neutrophil levels and requires infection prevention measures such as limiting exposure to pathogens. It does not inherently affect gait, vision, or motor coordination, so fall risk is not the primary concern.

D. A toddler who has strabismus is at greater risk for falls because misalignment of the eyes can interfere with depth perception and visual coordination. Toddlers are already prone to falls due to active exploration and immature motor control, and impaired vision increases this risk further. This combination makes fall prevention a priority for safety.