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CCRN Critical Care Nursing

Category - Neonatal

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A nurse in monitoring a 3-month-old infant for signs of increased intracranial pressure (ICP). On palapation of the fontanels, the nurse notes that the anterior fontanel is soft and flat. On the basis of this finding, which action should the nurse take next?

Elevate the head of the bed to 90 degrees
Notify the physician
Increase oral fluids
Document the finding

Explanation

Answer: D- The nurse would document the finding, since it is normal. The anterior fontanel is diamond shaped and located on the top of the head. It should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age.

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CCRN Critical Care Nursing

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