Ati paediatrics nursing assessment proctored exam
A nurse is assessing an infant who has hydrocephalus. Which of the following clinical manifestations should the nurse expect?
Explanation & Rationale
A. Depressed scalp veins Scalp veins would likely be distended or prominent due to increased intracranial pressure, not depressed. B. Sunken anterior fontanels The fontanelle would be bulging, not sunken, in hydrocephalus due to increased intracranial pressure. C. Bulging eyes Hydrocephalus does not typically cause bulging eyes. "Sunsetting eyes" (downward gaze with visible sclera above the iris) may be seen instead. D. Separated cranial sutures Increased intracranial pressure from excess cerebrospinal fluid (CSF) causes the sutures to separate due to skull expansion in infants.
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