Question

A nurse is assisting with the care of an infant who has spina bifida and recently had a ventriculoperitoneal shunt placed for hydrocephalus. Which of the following findings should the nurse identify as an indication of increased ICP?

A. Bulging fontanel

B. Decreased appetite

C. Increased lethargy

D. Increased urinary output

Answer 1

A bulging fontanel is an indication of increased intracranial pressure (ICP) in an infant with spina bifida and a ventriculoperitoneal shunt for hydrocephalus.

Step-by-step explanation:

A nurse should identify a bulging fontanel as an indication of increased intracranial pressure (ICP) in an infant with spina bifida and recently placed ventriculoperitoneal shunt for hydrocephalus.

Increased ICP can cause the fontanel, or soft spot on the infant's skull, to bulge due to the accumulation of cerebrospinal fluid (CSF) in the brain. This is a sign of increased pressure within the skull.

Options B, C, and D are not specific indicators of increased ICP in this scenario.