Question

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

A) Lower the head of the bed
B) Document the findings
C) Place the infant on NPO status
D) Notify the physician immediately

Answer 1

In this situation, the nurse should notify the physician immediately

Step-by-step explanation:

When a nurse caring for a hospitalized infant notices that the anterior fontanel bulges when the infant cries, it may indicate increased intracranial pressure (ICP). In this situation, the nurse should notify the physician immediately. Bulging of the anterior fontanel can be a sign of a serious condition that requires prompt medical attention. Lowering the head of the bed or placing the infant on NPO status (nothing by mouth) may not address the underlying cause of the increased ICP and delay necessary medical interventions. It is important for healthcare professionals to recognize and respond promptly to signs of increased ICP in infants.