Pediatrics Question #21

Question

A 6-month-old infant is admitted for treatment of bacterial meningitis and is showing signs of
increased intracranial pressure. Which assessment(s) should be the nurse’s priority? (Select all
that apply.)

Answers

  1. Assessing fontanels for bulging or tenseness.
    • Rationale:
  2. Assessing for increasing head circumference.
    • Rationale:
  3. Assessing signs of respiratory depression.
    • Rationale:
  4. Assessing for widening or narrowing pulse pressure.
    • Rationale:

Overview

Explanation

The correct answers are A and B. Increased intracranial pressure can cause a bulging fontanel. Increased intracranial pressure can cause an increase in head circumference. Respiratory depression is a late sign of increased intracranial pressure known as “Cushing’s Triad.” This would not be an immediate first priority assessment. Widening or narrowing pulse pressure is a late sign of increased intracranial pressure known as “Cushing’s Triad.” This would not be an immediate first priority assessment.

Learning Outcomes

Test Taking Tip

Video Rationale