Which of the following is the most concerning sign of increased intracranial pressure in an infant?
High-pitched cry.
Poor feeding.
Separated cranial sutures.
Bradycardia.
The Correct Answer is D
Choice A rationale
A high-pitched cry in an infant can be indicative of increased intracranial pressure (ICP) due to stretching of the meninges or irritation of the central nervous system. However, it is a non-specific sign that may also relate to pain or general distress. Normal infant crying is variable, but this specific quality suggests a potentially serious neurological issue.
Choice B rationale
Poor feeding is a non-specific sign of general illness in an infant, reflecting overall malaise or potentially a depressed level of consciousness secondary to increased ICP. Reduced appetite or difficulty sucking/swallowing suggests decreased neurological function or systemic distress but is often less immediately concerning than vital sign changes.
Choice C rationale
Separated cranial sutures (diastasis) and a bulging fontanelle are classic, late-stage physical findings in infants with chronic or acutely escalating ICP. The unfused sutures provide a compensatory mechanism for the expanding volume, but once separated, it signifies a substantial, long-standing pressure increase.
Choice D rationale
Bradycardia (abnormally slow heart rate) is the most concerning part of the Cushing's Triad (hypertension, bradycardia, and irregular respirations), which is a late and critical physiological response to dangerously elevated ICP. The reduced heart rate is a reflex response mediated by the brainstem to maintain cerebral perfusion pressure (CPP).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Choice A rationale
Drooling is a hallmark sign of epiglottitis because the severe inflammation and swelling of the epiglottis make swallowing extremely painful. The child is reluctant to swallow their saliva, which pools in the mouth and causes characteristic drooling, indicating a critical impending airway obstruction.
Choice B rationale
A barking cough, often described as a "seal-like" cough, is the classic presentation of croup (laryngotracheobronchitis), which involves subglottic inflammation. Epiglottitis, in contrast, primarily involves supraglottic inflammation, leading to a blocked, or muffled, vocalization rather than the resonant, inspiratory stridor and cough of croup.
Choice C rationale
A muffled or "hot potato" voice is highly suggestive of epiglottitis. The swollen epiglottis and surrounding supraglottic structures impede the air column and vocal cord vibration, altering the quality of speech but allowing air to pass, unlike the near-complete aphonia seen in other laryngeal obstructions.
Choice D rationale
Wheezing is a high-pitched whistling sound typically heard on expiration, caused by the narrowing of the lower airways (bronchi/bronchioles), common in conditions like asthma or bronchiolitis. Epiglottitis is a supraglottic obstruction, manifesting predominantly as inspiratory stridor, not wheezing.
Choice E rationale
The tripod position (sitting upright, leaning forward with the neck hyperextended and chin thrust out) is adopted by children with epiglottitis to maximize the patency of the swollen airway and facilitate breathing. This is a sign of significant respiratory distress and impending airway failure.
Correct Answer is A
Explanation
Choice A rationale
During a tonic-clonic seizure, loss of consciousness and uncontrolled muscle movements carry a high risk of aspiration if the child vomits or has excessive oral secretions. Turning the child to the side (recovery position) allows gravity to drain secretions and prevents the tongue from obstructing the posterior pharynx, which is the most critical immediate safety intervention.
Choice B rationale
While benzodiazepines (like rectal or intranasal diazepam or midazolam) are used to stop seizures, this is done via a non-oral route as the child is typically unconscious and unable to safely swallow during a seizure, posing a severe aspiration risk. Oral administration is contraindicated during the acute seizure event itself.
Choice C rationale
Inserting a tongue blade or any object into the mouth during a seizure is strictly contraindicated. The child's jaw may clamp down forcefully, causing injury to the child's teeth, gums, or jaw, or causing the object to break and obstruct the airway, leading to far more harm than benefit.
Choice D rationale
Restraining the child during a seizure is inappropriate and dangerous. The forceful muscle contractions can cause injury (fractures or dislocations) if movement is restricted against the convulsive forces. The nurse's role is to clear the area and protect the head and limbs from striking hard objects.
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