A nurse is performing an admission assessment on 6-month-old infant with a diagnosis of hydrocephalus. The nurse assesses for the major sign associated with hydrocephalus when the nurse:
  1. Tests the urine for protein
  2. Takes the apical pulse
  3. Palpates the anterior fontanel
  4. Tales the blood pressure
Explanation
Answer: C - In infants with hydrocephalus, the head at an abnormal rate, and the first sign of the disorder may be bulging fontanels without head enlargement. A bulging, tense, and nonpulsatile anterior fontanel indicates an increase in cerebrospinal fluid collection in the cerebral ventricle. A method of assessing fluid collection in the cranial cavity is to palpate the anterior fontanel.
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