A nurse is reviewing the medical record of a school-age child who has cystic fibrosis.

Which of the following findings should the nurse report to the provider? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

A. "Pinpoint pupils." A subdural hematoma typically causes unequal or dilated pupils due to increased intracranial pressure (ICP), rather than pinpoint pupils, which are more commonly associated with opioid toxicity or pontine damage.

B. "Sunken anterior fontanel." A sunken fontanel is a sign of dehydration. In cases of increased ICP, as seen with a subdural hematoma, the anterior fontanel is more likely to be bulging.

C. "Hypertonia." Neurological changes can occur, but hypotonia (decreased muscle tone) is more common in infants with increased ICP rather than hypertonia (increased muscle tone).

D. "Vomiting." Vomiting is a classic sign of increased ICP in infants, which occurs due to the pressure on the brainstem. Other symptoms may include irritability, a bulging fontanel, seizures, and lethargy.

A. Insert an oral airway for the child. Inserting an oral airway during a tonic-clonic seizure is not recommended, as it could cause injury to the child or block the airway. During a seizure, the priority is ensuring safety rather than trying to insert devices.

B. Apply soft restraints to the child's wrists. Restraints are not recommended during a seizure, as they can increase the risk of injury. Instead, the focus should be on protecting the child from injury and allowing the seizure to run its course.

C. Place a pillow under the child's knees. While positioning the child is important, placing a pillow under the knees is not a recommended action. The goal is to move the child to the floor to prevent falls or injury during the seizure.

D. Move the child to the floor. If a child is in a wheelchair and begins to have a seizure, moving them to the floor is the first step to prevent injury. Once the child is on the floor, ensure they are on their side to allow for airway clearance and reduce the risk of aspiration.