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?
  1. Elevate the head of the bed to 90 degrees
  2. Notify the physician
  3. Increase oral fluids
  4. 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.
Was this helpful? Upvote!
Login to contribute your own answer or details

Top questions

Related questions

Most popular on PracticeQuiz