153k views
0 votes
Which assessment leads a nurse to suspect that a newborn with a spinal cord lesion has increased intracranial pressure? Select all that apply.

A. ____ Irritability
B. ____ High-pitched cry
C. ____ Depressed fontanels
D. ____ Decreased urinary output
E. ____ Ineffective feeding behavior

1 Answer

2 votes

Final answer:

A nurse would suspect increased intracranial pressure in a newborn with a spinal cord lesion if the infant displays irritability, a high-pitched cry, and ineffective feeding behavior. Symptoms like decreased urinary output may also be relevant, although they are less directly associated with intracranial pressure. A bulging, not depressed, fontanel is a classic sign of increased intracranial pressure.

Step-by-step explanation:

To suspect that a newborn with a spinal cord lesion has increased intracranial pressure, a nurse would assess for certain clinical signs and symptoms. The assessments that can indicate increased intracranial pressure include:

  • A. Irritability
  • B. High-pitched cry
  • D. Decreased urinary output
  • E. Ineffective feeding behavior

These signs are indicative because they reflect neurological distress and can be associated with a compromised flow of cerebrospinal fluid (CSF) or cerebral blood flow, as seen in conditions like meningitis. Increased intracranial pressure in infants can cause symptoms such as a bulging fontanel (option C, depressed fontanels, would be incorrect as a bulging, not depressed, fontanel is a sign of increased pressure) and potential feeding difficulties due to the impact on the nervous system influencing swallow and suck reflexes.

User Scotty Bollinger
by
7.7k points