Question

The nurse is caring for a hospitalized infant and is monitoring for increased intracranial pressure (ICP). The nurse notes that the anterior fontanel bulges when the infant cries. Based on this finding, which action should the nurse take?

a. Document the finding
b. Report the finding to the healthcare provider
c. Assess the infant's vital signs
d. Encourage the parents to limit fluid intake

Answer 1

When the nurse notes that the anterior fontanel bulges when the infant cries, it is a sign of increased intracranial pressure (ICP). The appropriate action for the nurse to take is to report the finding to the healthcare provider.

Step-by-step explanation:

When the nurse notes that the anterior fontanel bulges when the infant cries, it is a sign of increased intracranial pressure (ICP). Increased ICP can be a serious condition that requires medical attention. Therefore, the appropriate action for the nurse to take is to report the finding to the healthcare provider so that further assessment and intervention can be done if necessary.