The nurse is monitoring an infant for signs of increased intracranial pressure (ICP). Which are late signs of increased intracranial pressure (ICP) in an infant?

A. While alterations in pupil size and reactivity are signs of increased ICP, increased motor response is not a late sign and typically reflects an early sign of brain dysfunction. B. Extension or flexion posturing may occur with increased ICP, but weight gain is not a sign of ICP. C. Tachycardia can occur early in ICP, but it does not typically present as a late sign. Altered pupil size and reactivity may occur, but these are not exclusive to late ICP signs. D. This is the correct answer. Cheyne-Stokes respirations, which are characterized by alternating periods of apnea and deep breathing, are a late sign of increased ICP in infants. Additionally, changes in pupil size (such as dilated or non-reactive pupils) are a late indicator of increasing intracranial pressure.