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. Vomiting: Vomiting is a common sign of increased intracranial pressure, which can occur with a subdural hematoma in infants. It often accompanies other neurological symptoms such as irritability or lethargy. B. Pinpoint pupils: Pinpoint pupils are more commonly associated with opioid overdose or pontine brain injury, not typically with subdural hematoma. Pupillary changes in subdural hematoma more often involve unequal or dilated pupils. C. Sunken anterior fontanel: A sunken fontanel indicates dehydration, not increased intracranial pressure. In subdural hematoma, the fontanel may be bulging or tense due to increased pressure. D. Hypertonia: Muscle tone changes can vary, but hypotonia (decreased tone) is more commonly seen in infants with brain injury. Hypertonia may occur later but is not a classic early sign of subdural hematoma.