A nurse is planning care for an infant with a bulging fontanel noted during an assessment. Which of the following actions should the nurse complete?
Explanation & Rationale
A. Applying a warm compress does not treat or relieve a bulging fontanel. This intervention is not appropriate because a bulging fontanel may indicate increased intracranial pressure, infection (such as meningitis), or hydrocephalus, all of which require urgent evaluation and treatment. B. A bulging fontanel is not a normal finding and should not be ignored. Continuing routine care without intervention could delay critical assessment and treatment, putting the infant at risk for serious complications. C. Waiting 24 hours to reassess is unsafe because a bulging fontanel can indicate an acute and potentially life-threatening condition. Immediate evaluation is necessary to prevent deterioration. D. A bulging fontanel in an infant may signal increased intracranial pressure, meningitis, hydrocephalus, or other serious neurological conditions. Prompt notification of the healthcare provider allows for rapid assessment, diagnostic testing, and timely intervention. Early recognition and response are essential to prevent complications such as brain injury or death.