CCRN Critical Care Nursing

Answer - D - A bulging and tensed anterior fontanel is indicative of increased intracranial pressure, a serious medical problem. Increased pressure can damage the brain or the spinal cord; therefore, it should be the nurse’s first priority. The child on a gluten-restricted diet would have adjusted to the diet and the child with an episode of seizure would have to be closely monitored. Though it is important to give preoperative preparations to the 10-year old for a tonsillectomy, it does not take priority over an infant with increased ICP.