A nurse is assisting in the care of an 8-month-old infant. Exhibits Complete the diagram by dragging from the choices below to specify what condition the infant is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters where the nurse should collect data to monitor the infant's progress.
Explanation & Rationale
Potential Condition: Increased intracranial pressure Actions to Take: Measure head circumference: This action is important to monitor for signs of increasing intracranial pressure, as a bulging and tense fontanel suggests possible hydrocephalus or other intracranial pathology. Plan to assist with administration of antibiotics: Antibiotics may be necessary if there is suspected meningitis or another infectious cause contributing to increased intracranial pressure. Parameters to Monitor: Behavioral changes: Monitor for irritability, difficulty to console, and other behavioral changes which can indicate neurological distress. Pupillary response: Assess for changes in pupillary size and reactivity, as altered pupillary responses can indicate neurological involvement and increased intracranial pressure.