A school nurse is assessing a child who fell from playground equipment and landed head-first. Which of the following manifestations should the nurse recognize as indicating the presence of increased intracranial pressure?

A. "Hyperextend your child's head for 5 minutes following a seizure."

This instruction is incorrect. Hyperextending the head after a seizure is not recommended and could potentially cause harm. Instead, it's important to ensure that the child's airway is clear and maintain a safe and comfortable position.

B. "Immediately following a seizure, give your child 6 ounces of water."

This instruction is not necessary unless the child specifically requests water or appears to be dehydrated. It's important to focus on ensuring the child's safety and comfort immediately after a seizure.

C. "Following a seizure, record the length and characteristics of your child's seizure."

This instruction is correct. Keeping a record of the length and characteristics of the child's seizures can provide valuable information to healthcare providers for managing the child's epilepsy and adjusting treatment as needed.

D. "Administer rectal diazepam to your child following a seizure."

This instruction may be appropriate in some cases, particularly if the child's seizures are prolonged or if they have a history of status epilepticus. However, the administration of rectal diazepam should be done according to the healthcare provider's instructions and with proper training.

E. "Call for emergency medical services if the size of your child's pupils are unequal after a seizure."

This instruction is correct. Unequal pupil size (anisocoria) after a seizure could indicate a serious underlying condition and should prompt immediate medical evaluation. It's important for the parents to be aware of this potential sign of concern and to seek prompt medical attention if it occurs.

A. Measuring the child's abdominal circumference:

This is the correct action. Assessing the child's abdominal circumference is essential in monitoring the size of the Wilms' tumor and evaluating for any signs of abdominal distention or growth. Changes in abdominal circumference can provide valuable information about the progression of the tumor and any potential complications.

B. Palpating the child's abdomen:

Palpating the child's abdomen is an essential part of the physical examination to assess for the presence of a mass or any tenderness. However, in the case of a child with a known Wilms' tumor, palpation should be performed gently to avoid causing discomfort or disturbing the tumor.

C. Providing clear liquids up to 1 hr prior to surgery:

Providing clear liquids up to 1 hour prior to surgery is not appropriate for a child undergoing surgery, especially if anesthesia is involved. Preoperative fasting guidelines typically require clear liquids to be stopped a few hours before surgery to reduce the risk of aspiration.

D. Continuously monitoring the child's oxygen saturation:

Continuous monitoring of the child's oxygen saturation is an essential aspect of perioperative care, but it is not specific to the preoperative assessment for a child with Wilms' tumor. Oxygen saturation monitoring is typically performed throughout the perioperative period to ensure adequate oxygenation during surgery and recovery.