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    Ati rn pediatric nursing 2023 proctored exam

    A nurse is caring for a 6-month-old infant who has a subdural hematoma. Which of the following findings should the nurse expect?

    Explanation & Rationale

    A. Sunken anterior fontanel: A sunken fontanel is typically associated with dehydration, not increased intracranial pressure. In the case of a subdural hematoma, the anterior fontanel would more likely be bulging due to pressure buildup. B. Vomiting: Increased intracranial pressure from a subdural hematoma can stimulate the vomiting center in the brain. Vomiting is a common expected finding and serves as an important clinical indicator of worsening pressure. C. Pinpoint pupils: Pinpoint pupils are usually linked to opioid intoxication or pontine brainstem injury, not subdural hematoma. In hematomas, pupils are more likely to become unequal or sluggishly reactive as intracranial pressure increases. D. Hypertonia: While changes in muscle tone can occur with neurological injury, hypertonia is not the most specific or expected finding in infants with subdural hematoma. Vomiting is a more consistent and direct indicator of increased intracranial pressure.

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