Ati rn 302 paediatrics proctored exam
A nurse is assessing an infant following a motor vehicle crash. Which of the following findings should the nurse monitor to identify increased intracranial pressure?
Explanation & Rationale
Rationale: A. Brisk pupillary reaction is normal and does not indicate increased intracranial pressure (ICP). B. Increased sleepiness or lethargy is an early sign of ICP in infants, along with irritability, poor feeding, and decreased responsiveness. C. Depressed fontanels are associated with dehydration, not increased ICP. D. Tachycardia is not an early sign of ICP; bradycardia may occur in later stages as part of Cushing’s triad.
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