Which of the following signs is most indicative of hydrocephalus in an infant?
Setting-sun sign.
High-pitched cry.
Sunken fontanel.
Normal head circumference.
The Correct Answer is A
Choice A rationale
The setting-sun sign is a clinical finding where the infant's eyes appear to be driven downward, with the sclera visible above the iris, resembling the sun setting below the horizon. This is highly indicative of hydrocephalus as the increased intracranial pressure (ICP) presses on the midbrain tectum, causing paralysis of upward gaze.
Choice B rationale
A high-pitched, shrill cry is a non-specific sign of neurological distress and is often associated with increased intracranial pressure (ICP). While it can occur with hydrocephalus, it is a less specific and less consistent finding than the setting-sun sign, which directly reflects the mechanical pressure effects on the oculomotor and associated midbrain structures.
Choice C rationale
A sunken or depressed fontanel is a classic sign of dehydration or hypovolemia due to decreased intracranial volume. Conversely, an infant with hydrocephalus, characterized by excessive cerebrospinal fluid accumulation, will typically present with a bulging, tense, and non-pulsatile anterior fontanel due to the severely elevated intracranial pressure.
Choice D rationale
Normal head circumference would be an unexpected finding in an infant with significant, uncompensated hydrocephalus. The defining clinical feature in infants is the rapid and often exaggerated increase in head circumference (macrocephaly), as the cranial sutures are not yet fused, allowing the head to expand markedly to accommodate the accumulating cerebrospinal fluid and rising pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.5"]
Explanation
Step 1 is: 520 mL÷ 8 hours = 65 mL/hr.
Step 2 is: 65 mL/hr÷ 42 kg = 1.5476. mL/kg/hr.
Step 3 is: Round the result to the nearest tenth: 1.5 mL/kg/hr. Final calculated answer: 1.5.
Correct Answer is D
Explanation
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).
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