Editing Pediatric Nursing – RN Practice Questions (section)

==Question 11==
A 7-month-old is admitted after a fall. Which assessment findings would lead the nurse to suspect '''increased intracranial pressure'''? '''Select all that apply.'''
# Tense, bulging anterior fontanel while the infant is quiet and supine with the head elevated
# High-pitched, shrill cry
# Widely separated cranial sutures with an enlarging head circumference
# Heart rate rising from 130 to 180 beats per minute with narrowing pulse pressure
# Poor feeding and repeated vomiting without diarrhea
# Setting-sun sign with the sclera visible above the iris

'''Answer:''' 1, 2, 3, 5, and 6.

''Rationale:'' In an infant with open sutures, rising intracranial pressure produces a bulging fontanel at rest, suture separation with abnormal head growth, a high-pitched cry, vomiting without diarrhea, poor feeding, and the setting-sun sign. Option 4 describes the wrong direction of change: the Cushing response to markedly elevated intracranial pressure is '''bradycardia''' with '''widening''' pulse pressure and irregular respirations, and it is a very late finding. Note that transient fontanel bulging during crying, coughing, or vomiting is normal, which is why option 1 specifies a quiet infant.