A nurse is caring for an infant who has hydrocephalus and ventriculoperitoneal shunt malfunction. Which of the following assessment findings indicates that the infant is experiencing increased intracranial pressure?

A. Insert an indwelling urinary catheter during the procedure: An indwelling urinary catheter is not routinely required for a lumbar puncture in a child. It is invasive and only indicated if the child cannot void independently or if prolonged immobility is expected, which is not the case here.

B. Ensure the child voids prior to the procedure: Having the child void before the lumbar puncture helps reduce discomfort, prevent bladder injury, and facilitates proper positioning during the procedure. It is a standard pre-procedure nursing action.

C. Monitor for paresthesia and tingling in extremities following the procedure: Paresthesia, numbness, or tingling can indicate nerve irritation or injury during the lumbar puncture. Monitoring neurologic status after the procedure is essential to detect complications early.

D. Ensure the guardian has signed the consent form prior to the procedure: Obtaining informed consent from the guardian is legally and ethically required before performing an invasive procedure like a lumbar puncture. It ensures that the guardian understands the risks, benefits, and alternatives.

E. Apply pressure to the puncture site following the procedure: Applying gentle pressure after the lumbar puncture helps prevent bleeding, reduces the risk of hematoma, and minimizes post-procedure complications such as CSF leakage.

F. Limit the child's fluid intake following the procedure: Limiting fluid intake is not indicated after a lumbar puncture. In fact, encouraging fluids may help prevent post-lumbar puncture headache by maintaining CSF volume.

G. Position the child in a prone position during the procedure: The correct position for a lumbar puncture is usually lateral recumbent or sitting with the back flexed to widen the intervertebral spaces. Prone positioning is inappropriate for this procedure.

A. Use a bulb syringe to suction the nares: Infants with bronchiolitis often have nasal congestion that can interfere with breathing and feeding. Using a bulb syringe to gently suction the nares helps maintain airway patency and promotes effective oxygenation, which is a key nursing intervention for this age group.

B. Administer a meningococcal vaccine upon admission: Meningococcal vaccination is not indicated for the acute management of bronchiolitis. Immunizations are typically given according to routine schedules and are not part of emergency care for viral respiratory infections.

C. Place the infant in a room with negative-pressure airflow: Negative-pressure rooms are primarily used for airborne infections such as tuberculosis. Bronchiolitis is spread through droplet transmission, so standard or contact precautions are sufficient, making negative-pressure rooms unnecessary.

D. Initiate IV antibiotic therapy: Bronchiolitis is most commonly caused by viral pathogens, such as respiratory syncytial virus (RSV), and does not require antibiotics unless there is a secondary bacterial infection. Routine IV antibiotic therapy is not indicated for uncomplicated bronchiolitis.