The nurse is assessing a 2-week-old infant who developed hydrocephalus. Which assessment finding by the nurse confirms this condition?
Explanation & Rationale
Choice A rationale Excessive thirst (polydipsia) is not a primary or direct symptom of hydrocephalus, which is the accumulation of cerebrospinal fluid (CSF) in the brain's ventricles. Polydipsia is more commonly associated with conditions causing fluid loss, such as diabetes insipidus or uncontrolled diabetes mellitus, and does not reflect the increased intracranial pressure and physical enlargement of the skull characteristic of hydrocephalus. Choice B rationale An infant with hydrocephalus typically exhibits a high-pitched, shrill cry, often described as a "cat-like" cry or a "neurologic" cry. This distinctive cry pattern is caused by the increased intracranial pressure straining the infant's vocal cords and brainstem structures. A soft or fretful cry is a more nonspecific finding, inconsistent with the severity of increased intracranial pressure associated with developing hydrocephalus. Choice C rationale Hypothermia (body temperature < 97.7°F or 36.5°C) is not a typical initial sign of hydrocephalus. While severe, prolonged intracranial pressure can affect the hypothalamus (the body's thermoregulatory center), early or mild hydrocephalus primarily manifests as signs related to CSF accumulation and pressure, such as fontanel changes, not a core temperature irregularity. Choice D rationale Widened, tense, and bulging fontanels are a hallmark sign of increased intracranial pressure (ICP) in infants whose cranial sutures have not yet fused. Hydrocephalus causes excessive cerebrospinal fluid to accumulate, which directly increases pressure within the skull. The resulting outward pressure causes the anterior fontanel to become tense, non-pulsatile, and often visibly bulging when the infant is in an upright position.