Practice Quiz

CCNS Certified Clinical Nurse Specialist

Category - Neonatal

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A mother arrives in an emergency room with her infant and the mother states that the child fell off a bunk bed. A head injury is suspected and a nurse is assessing the child continuously for signs of increased intracranial pressure (ICP). Which of the following is a late sign of increased ICP in this child?
  1. Nausea
  2. Bradycardia
  3. Bulging fontanel
  4. Dilated scalp veins
Explanation
Answer - B - A late sign of increased ICP in this patient is bradycardia. Late signs of increased intracranial pressure (ICP) include a significant decrease in level of consciousness, bradycardia, and fixed and dilated pupils. A bulging fontanel and dilated scalp veins are early signs of increased ICP and would be noted in an infant, not a 5-year-old child. Nausea is an early sign of increased ICP.
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