A nurse is evaluating an infant who received treatment for increased intracranial pressure. Which of the following findings should the nurse identify as an indication that the treatment was effective?
Soft, flat fontanels
Increased sleepiness
Enlarged head circumference
Crying when disturbed
The Correct Answer is A
A. Soft, flat fontanels: A soft, flat fontanel indicates that intracranial pressure has decreased and is within normal limits. Elevated pressure often causes bulging or tense fontanels, so this finding suggests effective treatment.
B. Increased sleepiness: Excessive sleepiness or lethargy can indicate worsening or ongoing increased intracranial pressure, so it is not a sign of effective treatment and requires further assessment.
C. Enlarged head circumference: An increasing head circumference in an infant can be a sign of accumulating cerebrospinal fluid or brain swelling, indicating persistent or worsening increased intracranial pressure.
D. Crying when disturbed: While crying is a normal infant behavior, excessive irritability or inconsolable crying may indicate discomfort or increased intracranial pressure rather than improvement. Normal, calm behavior is preferable after treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. No head lag when pulled into a sitting position: By 2 months, some head lag may still be present when pulling the infant to a sitting position. Full control of the head without lag typically develops closer to 4 months of age.
B. Lifts head 45° when lying prone: At 2 months, infants generally can lift and hold their head at about a 45-degree angle when placed on their stomach. This demonstrates early neck muscle strength and control appropriate for this age.
C. Rolls over from abdomen to back: Rolling over usually occurs later, around 4 to 6 months. It is not an expected gross motor milestone for a 2-month-old infant.
D. Rolls over from back to abdomen: This is a more advanced motor skill that typically develops between 5 to 6 months of age and would not be expected at 2 months.
Correct Answer is ["A","B","C","G","H","I","J"]
Explanation
Rationale for Correct Answers:
- Mucous membranes pink and moist: Reflects adequate hydration and improved fluid status compared to previous "dry and sticky" description.
- Respirations are regular/ RR 24/min: Indicates stable respiratory function with no signs of distress or respiratory compromise as compared to the previous irregular respirations
- HR 104/min / BP 104/80 mm Hg: Demonstrates cardiovascular stability within age-appropriate ranges and an improvement from the initial readings
- Radial pulse 2+ bilateral / Cap refill < 2 seconds: Suggests good perfusion and improved circulatory status compared to previous delayed cap refill and weak pulses.
- SpO₂ 98% on room air: Demonstrates sufficient oxygenation without need for respiratory support and an improvement from 97%.
Rationale for Incorrect Choices:
- Drowsy and lethargic, but responsive to verbal stimuli: Neurologic status has not improved from the previous day; continued lethargy and altered mental status require ongoing evaluation.
- Nuchal rigidity present: This is a classic sign of meningeal irritation and ongoing central nervous system involvement; it has not resolved and remains concerning.
- Temperature 38.9°C (102°F): The elevated temperature indicates persistent fever, suggesting that the infection or inflammation is still active.
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