PEDS CHAPTER 16 PREPU

The nurse is assessing the neurological functioning of a preschool child. What actions will best review functioning of cranial nerve III? A bright-colored toy is moved in the child's visual fields. The nurse talks softly to the child to note the ability to hear. The nurse observes facial features and expressions for symmetry. The nurse allows the child to smell objects and describe them

A bright-colored toy is moved in the child's visual fields. Explanation: Cranial nerve III, the oculomotor nerve, is assessed by using a brightly colored object to assess the child's ability to watch its movement. Cranial nerve I (olfactory nerve) controls the sense of smell. Asking the child to smell objects would be an assessment of this cranial nerve. Cranial nerve VII (facial nerve) is assessed by monitoring symmetry of facial movements. Cranial nerve VIII (acoustic nerve) is assessed by whispering.

At a well-child visit, hydrocephalus may be suspected in an infant if upon assessment the nurse finds: Narrow sutures Sunken fontanels A rapid increase in head circumference Increase in weight since last visit

A rapid increase in head circumference

A nurse demonstrates understanding of the various levels of consciousness as they progress from most alert to least alert. Place the levels of consciousness in the order that reflects this progression. You Selected: Oriented to person, place, and time Disorientation Obtundation Stupor Coma

Oriented to person, place, and time Disorientation Obtundation Stupor Coma Explanation: Levels of consciousness in order from most alert to least alert are orientated to person, place, and time (full consciousness); confusion (disorientation); obtundation; stupor; and finally coma.

A 10-year-old child is admitted to the hospital due to history of seizure activity. As his nurse, you are called into the room by his mother, who states he is having a seizure. What would be the priority nursing intervention? Prevention of injury by removing the child from his bed Prevention of injury by placing a tongue blade in the child's mouth Prevention of injury by restraining the child Prevention of injury by placing the child on his side and opening his airway

Prevention of injury by placing the child on his side and opening his airway

A 9-year-old client who suffered a head injury has strabismus. The nurse assesses the client for intracranial pressure (ICP). Which additional intervention is most important for the nurse to perform? Assess the level of consciousness (LOC). Notify the primary health care provider. Place the child on fall precaution. Place a patch over the client's affected eye.

Assess the level of consciousness (LOC). Explanation: Decreased LOC is frequently the first sign of a major neurologic problem after head trauma. The nurse would assess the client's LOC before notifying the health care provider. The child may need to be placed on fall precaution, depending on the results of the assessment. The child's eyes will correct themselves when the ICP is reduced; therefore, an eye patch is not necessary.

The nurse is observing an infant who may have acute bacterial meningitis. Which finding might the nurse look for? a) Irritability, fever, and vomitingb) Negative Kernig's signc) Flat fontaneld) Jaundice, drowsiness, and refusal to eat

a

Gabapentin has been prescribed for a pediatric client. Which statement by the client indicates an understanding of teaching related to the medication? "This medication will make me extremely hungry." "This medication should be taken in the evening before I go to bed." "This medication can be sprinkled on my food." "I can't take this medication within 2 hours of taking my antacid medication."

"I can't take this medication within 2 hours of taking my antacid medication." Explanation: Gabapentin is used in the treatment of seizure disorders. It is rapidly absorbed. It cannot be taken within 2 hours of the administration of antacid medications.

After teaching a group of students about neural tube disorders, the instructor determines that additional teaching is needed when the students identify which condition as a neural tube defect? spina bifida occulta encephalocele hydrocephalus anencephaly

hydrocephalus Explanation: Hydrocephalus results from an imbalance in the production and absorption of cerebrospinal fluid. In hydrocephalus, cerebrospinal fluid accumulates within the ventricular system and causes the ventricles to enlarge and increases in intracranial pressure. Anencephaly, encephalocele and spina bifida occulta are all neural tube defects.

An otherwise healthy 18-month-old child with a history of febrile seizures is in the well-child clinic. Which statement by the parent indicates to the nurse that additional teaching is needed? "The most likely time for a seizure is when the fever is rising." "I always keep phenobarbital with me in case of a fever." "My child will likely outgrow these seizures by age 5." "I have ibuprofen available in case it is needed."

"I always keep phenobarbital with me in case of a fever." Explanation: Anticonvulsants, such as phenobarbital, are administered to children with prolonged seizures or neurologic abnormalities. Ibuprofen, not phenobarbital, is given for fever. Febrile seizures usually occur after age 6 months and are unusual after age 5. Treatment is to decrease the temperature before a seizure occurs, which will most likely happen as the temperature rises.

Which nursing assessment data should be given the highest priority for a child with clinical findings related to meningitis? Onset and character of fever Degree and extent of nuchal rigidity Signs of increased intracranial pressure (ICP) Occurrence of urine and fecal contamination

Signs of increased intracranial pressure (ICP) Explanation: Assessment of fever and evaluation of nuchal rigidity are important aspects of care, but assessment for signs of increasing ICP should be the highest priority due to the life-threatening implications. Urinary and fecal incontinence can occur in a child who's ill from nearly any cause but doesn't pose a great danger to life.

Which of the following age groups of children have the highest actual rate of death from drowning? a) School-age children b) Toddlers c) Preschool children d) Infants

Toddlers

The nurse is caring for a child with suspected increased intracranial pressure (ICP). Which assessment finding would indicate increased ICP? tachypnea poor handwriting hyperthermia hypertension

hypertension Explanation: Symptoms of increased intracranial pressure include slowing of both pulse and respirations, increasing blood pressure, and the development of hypothermia. All of these symptoms result from the increased ICP putting pressure on the cranial vessels and the hypothalamus. Double vision, or diplopia, also occurs as a result of increasing ICP.

A 6-year-old has had a viral infection for the past 5 days and is having severe vomiting, confusion, and irritability, although he is now afebrile. During the assessment, the nurse should ask the parent which question? "Did you use any medications, like aspirin, for the fever?" "What type of fluids did your child take when he had a fever?" "Did you give your child any acetaminophen, such as Tylenol?" "How high did his temperature rise when he was ill?"

"Did you use any medications, like aspirin, for the fever?" Explanation: Severe and continual vomiting, changes in mental status, lethargy, and irritability are some of the signs and symptoms of Reye syndrome, which can occur as a result of ingesting aspirin or aspirin-containing products during a viral infection. Tylenol (acetaminophen) is allowed for viral infections in the school-age child. The type of fluids consumed during the illness has nothing to do with Reye syndrome. The temperature rise would be important for a much younger child because of the chance of febrile seizures, but not in this age child.

The mother of a toddler tells the nurse during a routine well-child appointment that she is concerned because, "It seems like my son is falling and hitting his head all of the time." What is the best response by the nurse? "You probably don't have anything to worry about. It is common for toddlers to fall." "I understand your concern, but toddlers fall and hit their heads a lot since they are not very coordinated yet." "Due to the size of their heads and immature neck muscles falling is common, but I will let the physician know your concerns." "Most mothers are concerned because their toddlers fall a lot. As long as your child seems to be developmentally normal it shouldn't be a concern."

"Due to the size of their heads and immature neck muscles falling is common, but I will let the physician know your concerns." Explanation: The head of the infant and young child is large in proportion to the body, and is the fastest-growing body part during infancy and continues to grow until the child is 5 years old. In addition, the infant's and child's neck muscles are not well developed. Both of these differences lead to an increased incidence of head injury from falls. The nurse should still let the physician know the mother's concerns in case there is another issue causing the falls.

The mother of a newborn with a caput succedaneum asks the nurse how this happened to her baby. Which response by the nurse would be most appropriate? "During delivery, your vaginal wall put pressure on the baby's head." "The forceps used during delivery caused this to happen." "Your baby's head became blocked inside your vagina while you were pushing." "It's normal for this to happen, but they don't really know why."

"During delivery, your vaginal wall put pressure on the baby's head." Explanation: Caput succedaneum results from pressure from the uterus or vaginal wall during a head-first delivery. The use of forceps is associated with a cephalohematoma. Caput succedaneum is not due to the baby's head becoming blocked inside the vagina. The cause of caput succedaneum is known; it is caused by pressure from the uterus or vaginal wall during a head-first delivery.

The nurse helps position a child for a lumbar puncture. Which statement describes the correct positioning for this procedure? "The child will be held by the mother on her lap with his back toward the health care provider." "When positioning the child, the nurse needs to assist the child to a side-lying position and keep his back as flat as much as possible." "The child will be placed in the prone position with the nurse holding the child still." "For a lumbar puncture, the child will be placed in a side-lying position with knees bent and neck flexed to assist with arching the back."

"For a lumbar puncture, the child will be placed in a side-lying position with knees bent and neck flexed to assist with arching the back." Explanation: Correct positioning for a lumbar puncture is to place the child on his or her side with the neck flexed and knees bent and drawn up to their chest. This helps to keep the back arched as much as possible. Newborns may be seated upright with their head bent forward. The child is not placed prone; this does not allow the back to be arched.

An infant with a ventriculoperitoneal (VP) shunt in place is brought to the clinic because of being drowsy and less responsive. Which question in the health history would provide information to the nurse indicating that the VP shunt is perhaps infected? "Have you noticed any changes in your child's pupils?" "Has your child been eating well the last few days?" "Has your child been crying more than usual?" "Has your child been sleeping more every day?"

"Has your child been eating well the last few days?" Explanation: The major complications for children who have shunts are infection and shunt malfunction. The symptoms a child would exhibit with an infection are poor feeding; increased temperature and heart rate; decreased responsiveness; and localized inflammation along the shunt tract. With a shunt malfunction, the child would have vomiting, drowsiness, and a headache. The nurse would be correct in asking about feeding as a way to indicate infection. Sleeping more and crying, if having a headache, could indicate a shunt malfunction. Pupil changes could indicate increased intracranial pressure. Parents who have children with shunt placements are taught all these symptoms, including pupil checks.

The nurse is caring for a child who has suffered a febrile seizure. While speaking with the child's parents, which statement by a parent indicates a need for further education? "The next time he has a fever, I need to make sure I read the dosage on the acetaminophen bottle carefully." "I need to set an alarm to wake up and check his temperature during the night when he is sick." "I hate to think that I will need to be worried about my child having seizures for the rest of his life." "When he gets his next set of immunizations, I need to make sure I give him some ibuprofen so he doesn't spike a fever."

"I hate to think that I will need to be worried about my child having seizures for the rest of his life." Explanation: Febrile seizures occur most often in preschool children but can occur as late as 7 years of age. They occur when the child has a rapid rise in temperature and are not associated with the development of seizures later in life. Administering correct dosages of acetaminophen and ibuprofen, checking temperatures at night, and anticipating fevers associated with the administration of live vaccines are all ways to prevent the development of febrile seizures.

The nurse is providing teaching to the parents of a child recently prescribed carbamazepine for a seizure disorder. Which statement by a parent indicates successful teaching? "I'm glad to know he will only need this medication for a short time to stop his seizures." "I need to watch for any new bruises or bleeding and let my health care provider know about it." "This medication may cause him to have trouble sleeping. He may need something else to help him sleep." "I will give the medication to him when I first wake him up in the morning."

"I need to watch for any new bruises or bleeding and let my health care provider know about it." Explanation: Carbamazepine is an antiseizure medication. It can cause bone marrow depression, so parents need to watch for any signs of bruising, bleed, or infection and notify their health care provider if this happens. Administer this medication with food to minimize GI upset. This medication can cause drowsiness, so do not give any sleep-inducing or other sedative type medications. Antiseizure medication does not cure seizures; it only controls the seizures. Lifelong antiseizure medication may be needed.

The parents of a 17-year-old adolescent diagnosed with bacterial meningitis tell the nurse, "We just do not understand how this could have happened. Our adolescent has always been healthy and just received a booster vaccine last year." How should the nurse respond? "Maybe your child's immune system is not strong enough to fight off the infection, even with having received the vaccine." "I understand your frustration. Unfortunately, immunizations are not 100% effective in preventing the infection." "Your child may have been exposed to the type of meningitis that is not covered by the vaccine received." "Meningococcal conjugate vaccine covers only two types of bacterial meningitis."

"I understand your frustration. Unfortunately, immunizations are not 100% effective in preventing the infection." Explanation: Showing empathy while letting the parents know that vaccines are not 100% effective is the best response. Meningococcal conjugate vaccine protects against four types of meningitis. There is nothing in the scenario to lead the nurse to believe that a different strain of bacteria caused the infection, or that the adolescent's immune system is compromised.

While caring for a child who will be undergoing a lumbar puncture, the nurse explains the procedure to the infant's mother. Which statement by the mother would indicate a need for further education? "My child may have a headache after the procedure. If she does, she can have something for the pain." "I need to encourage my child to drink at least 1 glass of water after the procedure." "I will cradle her in my arms after the procedure for at least 30 minutes." "During the test, the health care provider will most likely take 3 tubes of spinal fluid to test for several things."

"I will cradle her in my arms after the procedure for at least 30 minutes." Explanation: During the procedure, typically 3 tubes of cerebrospinal fluid (CSF) are removed for testing. After the procedure, the child is encouraged to lay flat for at least 30 minutes. During that time, the child is also encouraged to drink a glass of water to help prevent cerebral irritation. Even when all proper procedures are followed, some children develop a headache following the test. An analgesic may be given for pain relief.

The nurse is caring for a 3-year-old child who experienced a febrile seizure for the first time. What statements by the parents of the child should the nurse address further? Select all that apply. "It is so scary to think that our child will likely develop epilepsy now." "I am thankful that our child won't have to be on anti-seizure medication." "It's important to manage fevers in the future in order to decrease the risk of febrile seizures." "We have never had anyone in our family have a febrile seizure so I was so surprised when this happened." "I am afraid that our 10-year-old will start having febrile seizures

"It is so scary to think that our child will likely develop epilepsy now." "I am afraid that our 10-year-old will start having febrile seizures." Explanation: It is very unlikely that the 10-year-old child will develop febrile seizures. Febrile seizures usually affect children who are younger than 5 years of age, with the peak incidence occurring in children between 12 and 18 months old; it is rare to see febrile seizures in children younger than 6 months and older than 5 years of age. Children who experience one or more simple febrile seizures have a slightly greater risk of developing epilepsy than the general population, so it is not "likely" that the child will develop epilepsy.

x The nurse is caring for an infant who is at risk for increased intracranial pressure. What statement by the parent would alert the nurse to further assess the child's neurological status? "She always cries when the person holding her has on glasses...I guess glasses scare her." "She typically breastfeeds, but lately we have had to supplement with some oat cereal." "She has been irritable for the last hour....seems like she is just upset for some reason." "She is a pretty happy baby, unless her diaper is wet, then she cries until we change her diaper."

"She has been irritable for the last hour....seems like she is just upset for some reason." Explanation: Irritability in an infant can be a sign of declining neurological function. Because infants are not able to answer questions pertaining to person, place and time, their neurological assessment must be catered to their level of development. The other responses would be typical and normal for an infant.

The parents of a child with a history of seizures who has been taking phenytoin ask the nurse why it's difficult to maintain therapeutic plasma levels of this medication. Which statement by the nurse would be most accurate? "The capacity to metabolize the drug becomes overwhelmed over time." "Large increments in dosage lead to a more rapid stabilizing therapeutic effect." "A drop in the plasma drug level will lead to a toxic state." "Small increments in dosage lead to sharp increases in plasma drug levels."

"Small increments in dosage lead to sharp increases in plasma drug levels." Explanation: Within the therapeutic range for phenytoin, small increments in dosage produce sharp increases in plasma drug levels. The capacity of the liver to metabolize phenytoin is affected by slight changes in the dosage of the drug, not necessarily the length of time the client has been taking the drug. Large increments in dosage will greatly increase plasma levels, leading to drug toxicity.

The parent of a 12-year-old child with Reye syndrome approaches the nurse wanting to know how this happened to the child, saying, "I never give my children aspirin!" What could the nurse say to begin educating the parent? "Sometimes it is hard to tell what products may contain aspirin." "Do you think that maybe your child took aspirin on his or her own?" "Do not worry; you are in good hands. We have it under control now." "Aspirin in combination with the virus will make the brain swell and the liver fail."

"Sometimes it is hard to tell what products may contain aspirin." Explanation: Salicylates are in a wide variety of products, so consumers must read the small print very carefully or they will miss the warning. Two common medications containing salicylates are bismuth subsalicylate and effervescent heartburn relief antiacid. The parent needs to be receptive to further education, and raising the possibility the child was responsible does not accomplish that goal. The nurse should not state the obvious, but also should not minimize the situation. Encouraging the parent to ask for information and offering explanations in terms the parent will understand are important, but this response does not address the parent's assertion. Telling the parent not to worry is offering platitudes and false reassurance. Giving the description of what complications could happen with the disease would be inappropriate. This would only exacerbate the parent's concern, and it does not address how the child ingested salicylates.

A 1-year-old infant has just undergone surgery to correct craniosynostosis. Which comment is the best psychosocial intervention for the parents? "The surgery was successful. Do you have any questions?" "This only happens in 1 out of 2,000 births." "I told you yesterday there would be facial swelling." "I will be watching hemoglobin and hematocrit closely."

"The surgery was successful. Do you have any questions?" Explanation: Often what parents need most is someone to listen to their concerns. Although this is a good time for education, the parents are more concerned about the success of the surgery than their infant's appearance. Watching the hemoglobin, hematocrit and swelling are important nursing functions but they do not address the parents' psychosocial needs. The parents do not need to be taught statistics about their infant's condition. They more than likely know this from health care provider visits, the Internet, and parent support groups. Following surgery, this knowledge is not what parents are concerned about. Parents want to know their infant is safe and well

The nurse has performed discharge teaching for parents of a child diagnosed with epilepsy. The child has been prescribed Zonegran (zonisamide). Which comments by the parents indicate the need for further discharge teaching regarding this medication? Select all that apply. "This medication can make our child very sedated so we need to monitor for this side effect." "I hope this medicine doesn't upset our child's stomach when taking it since the medication should be given on an empty stomach." "Since our child also takes Dilantin (phenytoin), the dosages will likely be adjusted since it increases the metabolism of the Zonegran (zonisamide)." "We need to watch our child's gums for swelling since this commonly happens with this medicine." "We may need to add B-complex vitamin supplementation to our child's medications because this can help mange side effects."

"This medication can make our child very sedated so we need to monitor for this side effect." "We need to watch our child's gums for swelling since this commonly happens with this medicine." "We may need to add B-complex vitamin supplementation to our child's medications because this can help mange side effects." Explanation: Presence of food will delay absorption of the medication so it should not be administered with food. Phenytoin, phenobarbital, and carbamazepine all increase the metabolism of this drug. A side effect of phenobarbital is excessive sedation and gingival hyperplasia. B-complex vitamin supplementation can help manage side effects of levetiracetam.

A 7-year-old client has been complaining of headache, coughing, and an aching chest. The care provider makes a diagnosis of a viral infection. The child's mother tells the nurse that when she first said she had a headache, the child's father gave her half of an adult aspirin. The mother has heard of Reye syndrome and asks the nurse if her child could get this. Which statement would be the best response by the nurse? "This is a serious problem. Aspirin is likely to cause Reye syndrome, and she should be admitted to the hospital for observation as a precaution." "This is unlikely to be a problem. Half an aspirin is not enough to cause harm. Reye syndrome generally only develops from prolonged use of aspirin in connection with a virus." "This might or might not be a problem. Watch your daughter for signs of nasal discharge, sneezing, itching of the nose, or dark circles under the eyes. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome." "This might or might not be a problem. Watch your daughter for signs of lethargy, unusual irritability, confusion, or vomiting. If you notice any of these, bring her to the emergency room immedia

"This might or might not be a problem. Watch your daughter for signs of lethargy, unusual irritability, confusion, or vomiting. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome." Explanation: Reye syndrome usually occurs after a viral illness, particularly after an upper respiratory infection or varicella (chickenpox). Administration of aspirin during the viral illness has been implicated as a contributing factor. As a result, the American Academy of Pediatrics recommends that aspirin or aspirin compounds not be given to children with viral infections. The symptoms appear within 3 to 5 days after the initial illness: The child is recuperating unremarkably when symptoms of severe vomiting, irritability, lethargy, and confusion occur. Immediate intervention is needed to prevent serious insult to the brain, including respiratory arrest.

The nurse is educating the family of a 7-year-old with epilepsy about care and safety for this child. What comment will be most valuable in helping the parent and the child cope? "Bike riding and swimming are just too dangerous." "If he is out of bed, the helmet's on the head." "Use this information to teach family and friends." "You'll always need a monitor in his room."

"Use this information to teach family and friends." Explanation: Families need and want information they can share with relatives, child care providers, and teachers. Wearing a helmet and having a monitor in the room are precautions that may need to be modified as the child matures. The child may be able to bike ride and swim with proper precautions.

The nurse is providing education to the parents of a 2-year-old boy with hydrocephalus who has just had a ventriculoperitoneal shunt placed. Which information is most important for the parents to be taught? "Always keep his head raised 30 degrees." "Limit the amount of television he watches." "Watch for changes in his behavior or eating patterns." "Call the doctor if he gets a headache."

"Watch for changes in his behavior or eating patterns." Explanation: Changes in behavior or in eating patterns can suggest a problem with his shunt, such as infection or blockage. Irritability, lack of appetite, increased crying, or inability to settle down may indicate increased intracranial pressure. Any headache needs to be monitored, but if it goes away quickly, such as after eating, it probably isn't a problem. It is not necessary to keep the child's head raised 30 degrees. The child's shunt will not be affected by the amount of television viewed.

The emergency room nurse is taking a history of a 1-year-old child whose parent said that she had a "fit" at home. Which inquiry would be best to start with? "How did you treat the child afterwards?" "Was the child unconscious?" "What happened just before the seizures?" "Were there any jerky movements?"

"What happened just before the seizures?" Explanation: Asking what happened just before the seizure will suggest whether the episode was a seizure or a breath-holding event, which is frequently precipitated by an expression of anger or frustration. Cyanotic breath holding can be accompanied by clinical movements, as can seizures. Both types of events render the child unconscious. One would expect concerned, caring treatment from the parents regardless of the cause.

The meningococcal vaccine should be offered to high-risk populations. If never vaccinated, who has an increased risk of becoming infected with meningococcal meningitis? Select all that apply. 5-year-old child who routinely travels in the summer with her parents on mission trips to Haiti 8-year-old child who is in good health 12-year-old child with asthma 9-year-old child who was diagnosed with diabetes when he was 7 years old 18-year-old student who is preparing for college in the fall and has signed up to live in a dormitory with two other suite mates

18-year-old student who is preparing for college in the fall and has signed up to live in a dormitory with two other suite mates 12-year-old child with asthma 5-year-old child who routinely travels in the summer with her parents on mission trips to Haiti 9-year-old child who was diagnosed with diabetes when he was 7 years old Explanation: The following people have an increased risk of becoming infected with meningococcal meningitis: college freshman living in dormitories, children 11 years old or older, children who travel to high risk areas, and children with chronic health conditions.

A 6-year-old child with hydrocephalus had a ventriculoperitoneal (VP) shunt placed 6 weeks ago and now has experienced a seizure, vomiting, and loss of appetite. Which intervention will target the child's priority need? Pad and raise the rails on the child's bed. Administer intravenous antibiotics as prescribed. Prepare a menu with the child's favorite foods. Educate the parents about seizure precautions.

Administer intravenous antibiotics as prescribed. Explanation: The major complications associated with shunts are infection and malfunction. When a shunt malfunctions the child experiences vomiting, drowsiness, and headache. When infection has occurred the child experiences increased vital signs, poor feeding, vomiting, decreased responsiveness, seizure activity and signs of local inflammation along the shunt tract. When an infection occurs the priority of care is to treat the infection with IV antibiotics. The seizures and the poor eating will resolve once the infection is cleared. The parents can be taught about seizure precautions and the bed can be padded but these are not the priority of care.

The nurse is caring for a school-age child who has been having a continuous seizure for the last 40 minutes. What is the priority action by the nurse? Perform a glucose finger stick to determine the child's blood sugar level. Observe and document the length of time of the seizure and type of movement observed. Administer carbamazepine as prescribed. Administer lorazepam IV as prescribed.

Administer lorazepam IV as prescribed. Explanation: A seizure lasting longer than 30 minutes is considered status epilepticus and is an emergency situation. An IV benzodiazepine such as lorazepam is administered to help stop the seizure. Checking blood glucose levels, monitoring length and type of seizure, and administration of anti-seizure medication such as carbamazepine all are correct interventions for clients with seizures, but these are not the priority action.

The nurse is caring for a child diagnosed with hydrocephalus following ventriculoperitoneal shunt placement. The child is currently on a ventilator. Which nursing action is priority? Educate the family on the shunt. Monitor the client for signs of infection. Assess the client's respiratory status. Measure the client's head circumference

Assess the client's respiratory status. Explanation: The nurse would place priority on monitoring the client's respiratory status since the client is on a ventilator and at risk for intracranial pressure. The nurse would educate the family on the shunt, monitor for infection, and measure head circumference; however, these actions are not priority over ensuring the client maintains a patent airway.

A child has been diagnosed with a basilar skull fracture. The nurse identifies ecchymosis behind the child's ear. This would be documented as: raccoon eyes. Battle sign. rhinorrhea. otorrhea.

Battle sign. Explanation: Two signs of basilar skull fracture include Battle sign (bruising or ecchymosis behind the ear) and "raccoon eyes" (blood leaking into the frontal sinuses causing an edematous and bruised periorbital area). Rhinorrhea is CSF leakage from the nose. Otorrhea is CSF leaking from the ear.

Antibiotic therapy to treat meningitis should be instituted immediately after which event? Initiation of IV therapy Collection of cerebrospinal fluid (CSF) and blood for culture Admission to the nursing unit Identification of the causative organism

Collection of cerebrospinal fluid (CSF) and blood for culture Explanation: Antibiotic therapy should always begin immediately after the collection of CSF and blood cultures. After the specific organism is identified, bacteria-specific antibiotics can be administered if the initial choice of antibiotic therapy isn't appropriate. Admission and initiation of IV therapy aren't, by themselves, appropriate times to begin antibiotic therapy.

A preschool-age child has just been admitted to the pediatric unit with a diagnosis of bacterial meningitis. The nurse would include which recommendation in the nursing plan? Encourage the parents to hold the child Take vital signs every 4 hours Decrease environmental stimulation Monitor temperature every 4 hours

Decrease environmental stimulation Explanation: A child with the diagnosis of meningitis is much more comfortable with decreased environmental stimuli. Noise and bright lights stimulate the child and can be irritating, causing the child to cry, in turn increasing intracranial pressure. Vital signs would be taken initially every hour and temperature monitored every 2 hours. Children with bacterial meningitis are usually much more comfortable if allowed to lie flat because this position doesn't cause increased meningeal irritation.

The mother of an infant reports that her child is frequently choking when breastfeeding or taking a bottle. The nurse plans on assessing which cranial nerve when addressing the mother's concerns? VII VIII IX VI

IX Explanation: Cranial nerve IX (glossopharyngeal) would be assessed to test the swallowing and gag reflex. Cranial nerve VIII is the acoustic nerve which is involved in hearing. Cranial nerve VII is the facial nerve and controls facial muscles, salivation and taste. Cranial nerve VI is the abducens nerve and controls and is related to eye movements.

The nurse is caring for a child who has suffered a head injury and has had an ICP monitor placed. Which prescription by the health care provider would the nurse question? Place in an indwelling urinary catheter. Administer mannitol IV, dosage determined by the pharmacist. Administer dexamethasone, dosage determined by the pharmacist. Initiate an IV of 0.9% NS to run at 250 ml/hr.

Initiate an IV of 0.9% NS to run at 250 ml/hr. Explanation: Rapid administration of IV fluids may increase ICP. An IV rate of 250 ml/hr of normal saline can be considered a rapid infusion. Corticosteroids such as dexamethasone can reduce cerebral edema. Osmotic diuretics, such as mannitol, can reduce pressure. Because of the administration of the osmotic diuretic, indwelling urinary catheters are typically inserted.

A 6-month-old infant is admitted to the hospital with suspected bacterial meningitis. She is crying, irritable, and lying in the opisthotonic position. The priority nursing intervention would be: Educate the family on ways to prevent bacterial meningitis. Initiate appropriate isolation precautions and begin intravenous antibiotics. Assess the infant's fontanels. Encourage the mother to hold the infant and feed her.

Initiate appropriate isolation precautions and begin intravenous antibiotics.

A 6-month-old infant is admitted with suspected bacterial meningitis. She is crying, irritable, and lying in the opisthotonic position. Which intervention should the nurse take initially? Palpate the child's fontanels (fontanelles). Educate the family about preventing bacterial meningitis. Encourage the mother to hold and comfort the infant. Institute droplet precautions in addition to standard precautions.

Institute droplet precautions in addition to standard precautions.

Absence seizures are marked by what clinical manifestation? Brief, sudden onset of increased tone of the extensor muscle Loss of motor activity accompanied by a blank stare Sudden, brief jerks of a muscle group Loss of muscle tone and loss of consciousness

Loss of motor activity accompanied by a blank stare Explanation: An absence seizure consists of a sudden, brief arrest of the child's motor activity accompanied by a blank stare and loss of awareness. A tonic seizure consists of a brief onset of increased tone or muscle. A myoclonic seizure is characterized by sudden, brief jerks of muscle groups. An atonic seizure involves a sudden loss of muscle tone and loss of consciousness.

The nurse is collecting data from a child who may have a seizure disorder. Which nursing observations suggest an absence seizure? Brief, sudden contracture of a muscle or muscle group Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention Sudden, momentary loss of muscle tone, with a brief loss of consciousness Muscle tone maintained and child frozen in position

Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention Explanation: Absence seizures are characterized by a brief loss of responsiveness with minimal or no alteration in muscle tone. They may go unrecognized because the child's behavior changes very little. A sudden loss of muscle tone describes atonic seizures. A frozen position describes the appearance of someone having akinetic seizures. A brief, sudden contraction of muscles describes a myoclonic seizure.

A nurse is assessing a 3-year-old child for possible bacterial meningitis. Which sign would indicate irritation of the meninges? Positive Kernig sign Negative Brudzinski sign Positive Chadwick sign Negative Kernig sign

Positive Kernig sign Explanation: A positive Kernig sign can indicate irritation of the meninges. A positive Brudzinski sign also is indicative of the condition. A positive Chadwick sign is a bluish discoloration of the cervix indicating pregnancy.

While in a pediatric client's room, the nurse notes that the client is beginning to have a tonic-clonic seizure. Which nursing action is priority? Administer lorazepam rectally to the client. Refer the client to a neurologist. Discuss dietary therapy with the client's caregivers. Protect the child from hitting the arms against the bed.

Protect the child from hitting the arms against the bed. Explanation: Keeping the child safe during a seizure is the highest priority. The nurse will protect the child from hitting the arms on the bed or other nearby objects. If the seizure continues, lorazepam may be indicated to stop the seizure. The client would be referred to a neurologist for follow-up care; however, this is not a priority. Dietary therapy is considered for clients with chronic seizure disorders who do not respond to medication therapy.

In caring for the child with meningitis, the nurse recognizes that which nursing diagnosis would be most important to include in this child's plan of care? Risk for injury related to seizure activity Delayed growth and development related to physical restrictions Ineffective airway clearance related to history of seizures Risk for acute pain related to surgical procedure

Risk for injury related to seizure activity Explanation: The child's risk for injury would be an appropriate nursing diagnosis. Surgery is not indicated for the child with meningitis, and if the child has a history of seizures, it would specifically impact airway clearance. Growth and development issues are a concern but not likely delayed due to this diagnosis.

The nurse is providing education to the parents of a female toddler with hydrocephalus who has just had a shunt placed. Which statement is the best to make during a teaching session? Tell me your concerns about your child's shunt. Always keep her head raised 30º. Her autoregulation mechanism to absorb spinal fluid has failed. Call the doctor if she gets a persistent headache.

Tell me your concerns about your child's shunt. Explanation: Always start by assessing the family's knowledge. Ask them what they feel they need to know. Knowing when to call the doctor and how to raise the child's head are important, but they might not be listening if they have another question on their minds. "Autoregulation" is too technical; base information on the parents' level of understanding.

A school-aged child with seizures is prescribed phenytoin sodium, 75 mg four times per day. What instruction would the nurse give the parents regarding this medication? Numbness of the fingers is common while taking this drug The child will have to adhere to good tooth brushing Watching television while taking the drug may cause seizures Even small doses may cause noticeable dizziness

The child will have to adhere to good tooth brushing Explanation: A side effect of phenytoin sodium is gingival hyperplasia. Good tooth brushing helps prevent inflammation under the hypertrophied tissue. Dizziness and tingling and numbness of the fingers are not side effects of this drug. Television watching will not elicit a seizure in a child with a known seizure disorder. A seizure occurs as an electrical interference in the brain.

When compared with adults, why are infants and children at an increased risk of head trauma? The head of the infant and young child is large in proportion to the body and the neck muscles are not well developed. The development of the nervous system is complete at birth but remains immature. The spine is very immobile in infants and young children. The skull is more flexible due to the presence of sutures and fontanels.

The head of the infant and young child is large in proportion to the body and the neck muscles are not well developed.

When caring for a child who has a history of seizures, which nursing interventions would be appropriate? Select all that apply. The nurse places a washcloth in the mouth to prevent injury during seizure. The nurse positions the child on the side during a seizure. The nurse pads the crib or side rails before a seizure. The nurse stays with the child and calls for help when a seizure begins. The nurse has oxygen available to use during a seizure. The nurse teaches the caregivers regarding seizure precautions.

The nurse pads the crib or side rails before a seizure. The nurse positions the child on the side during a seizure. The nurse stays with the child and calls for help when a seizure begins. The nurse has oxygen available to use during a seizure. The nurse teaches the caregivers regarding seizure precautions. Explanation: The nurse should pad the crib sides and keep sharp or hard items out of the crib. The nurse should also position the child to one side to prevent aspiration of saliva or vomitus and have oxygen and suction equipment readily available for emergency use. The nurse should teach family caregivers seizure precautions so they can handle a seizure that occurs at home. The nurse should not put anything in the child's mouth; doing so could cause injury to the child or to the nurse. It is important for the nurse to promptly inform other members of the care team when a child is experiencing seizure activity, but leaving the bedside to do so would be unsafe.

The nurse is educating the parents of a 7-year-old girl with epilepsy about managing treatment of the disorder at home. Which intervention is most effective for eliminating breakthrough seizures? Treating the child as though she did not have epilepsy Understanding the side effects of medications Placing the child on her side on the floor Instructing her teacher how to respond to a seizure

Understanding the side effects of medications Explanation: The most common cause of breakthrough seizures is noncompliance with medication administration, which may occur if the parents do not understand what side effects to expect or how to deal with them. Treating the child as though she did not have epilepsy helps improve her self-image and self-esteem. Placing the child on her side on the floor is an intervention to prevent injury during a seizure. Instructing the teacher on how to respond when a seizure occurs will help relieve anxiety and provide a sense of control.

The nurse is assessing a toddler for motor function. Which activity will be the most valuable? Have the child catch a ball. Watch the child reach for a toy. Let the child look at a picture book. Ask the child to kick the ball forward.

Watch the child reach for a toy. Explanation: Watching the child reach for a toy would be most valuable for assessing motor function because the infant should be able to extend extremities to a normal stretch. Catching a ball or kicking a ball forward is too advanced for a toddler to accomplish. Looking at a picture book would help assess visual acuity and eye movement.

The nurse is caring for a child with a suspected head injury. The nurse observes for what response to the child's eye reflex examination that would indicate potential increased intracranial pressure (ICP)? While turning the child's head to the left, the eyes turn to the right. While stimulating the child's foot, the big toe points upward and other toes fan outward. While calling the child's name, the child stares straight ahead and does not turn to the sound. While assessing the child's pupils, there is no change in diameter in response to a light.

While assessing the child's pupils, there is no change in diameter in response to a light. Explanation: To perform the child's eye reflex examination, the nurse will shine a penlight into the eyes and observe if the pupils constrict, which is a normal response. Lack of pupillary light reflex can indicate increased intracranial pressure (ICP). To perform the "doll's eye" reflex examination, the nurse will place the child in a supine position and move the head gently but rapidly to one side. During this movement, it is normal for the child's eye to move to the opposite side. If the child has increased ICP, this response will be absent. While the other options are potential signs of increased ICP, they do not demonstrate the child's eye reflex examination.

The community health nurse is preparing a presentation on safety measures to prevent injuries in children. Which example of proper safety guidelines should the nurse include? Select all that apply. a child wearing a helmet while ice skating an infant in a car seat a child riding a scooter with elbow and knee pads a preschool-age child sitting on the lap of a caregiver in the back seat of a car a child wearing a helmet, knee pads, and elbow pads while riding a skateboard

a child wearing a helmet while ice skating an infant in a car seat a child wearing a helmet, knee pads, and elbow pads while riding a skateboard Explanation: Seat belts and child restraints such as car seats should always be used. Children should never ride on the lap of someone else in a car. Helmets should be worn while the child is riding or using anything that can move faster than the child can run. Examples of these are scooters, roller skates, ice skates, and skateboards.

A group of nursing students are reviewing cerebral vascular disorders and risk factors in children. The students demonstrate understanding of the material when they identify which as a risk factor for hemorrhagic stroke? meningitis sickle cell disease arteriovenous malformations (AVMs) congenital heart defect

arteriovenous malformations (AVMs) Explanation: Vascular malformations such as intracranial AVMs are a risk factor for hemorrhagic stroke. Sickle cell disease is a risk factor for ischemic stroke. Congenital heart defects are risk factors for ischemic stroke. Meningitis or other infection is a risk factor for ischemic stroke.

The nurse is completing a nursing history on a female client who has just found out she is 6 weeks' pregnant. She reports that over the last 2 months she has been drinking excessive amounts of alcohol every weekend and smokes a half-pack of cigarettes per day. What is the nurse concerned with given this information? Select all that apply. reproductive organ development in the fetus brain development in the fetus spinal cord development in the fetus solid bone formation in the fetus development of gastrointestinal organs in the fetus

brain development in the fetus spinal cord development in the fetus' Explanation: The brain and spinal cord make up the central nervous system (CNS). Development of these structures begins in the first 3 to 4 weeks of gestation from the neural tube. Infection, trauma, teratogens (any environmental substance that can cause physical defects in the developing embryo and fetus), and malnutrition during this period can result in malformations in brain and spinal cord development and may affect normal CNS development.

The nurse assesses a child and finds that the child's pupils are pinpoint. What does this finding indicate? brain stem herniation seizure activity brain stem dysfunction intracranial mass

brain stem dysfunction Explanation: Pinpoint pupils are commonly observed in poisonings, brain stem dysfunction, and opiate use. Dilated but reactive pupils are seen after seizures. Fixed and dilated pupils are associated with brain stem herniation. A single dilated but reactive pupil is associated with an intracranial mass.

The nurse and an adolescent are reviewing the adolescent's record of her headaches and activities surrounding them. What activity would the nurse identify as a possible trigger? use of nonaccented soap drinking three cans of diet cola swimming twice a week 11 p.m. bedtime; 6:30 a.m. wake-up

drinking three cans of diet cola Explanation: Cola contains caffeine, which is an associated trigger. Intense activity, not regular exercise, may be a trigger. Odors, such as strong perfumes, may be a trigger. Changes in sleeping patterns may be a trigger.

A nurse on the neurology unit is monitoring an 8-year-old child admitted with seizures. The child experiences a prolonged tonic-clonic seizure. Complete the following sentence(s) by choosing from the lists of options. The nurse should first Select...ensure proper oxygenationinsert an airway into the client's mouthsuction the client's airwaySelect... followed by Select...administer intravenous (IV) or intramuscular (IM) benzodiazepineadminister an antiepileptic by mouth (PO)do not allow the client to sleep once the seizure has endedSelect....

ensure proper oxygenation followed by administer intravenous (IV) or intramuscular (IM) benzodiazepine Explanation: The nurse first ensures a patent airway and proper oxygenation using a blow-by method.The nurse then administers an antiepileptic medication such as benzodiazepines intravenously or intramuscularly for prolonged seizure activity. Nothing should be inserted into the child's airway when the child is seizing, not even suction. The nurse can place the child in a side-lying position to prevent the tongue from occluding the airway and help with secretions that may pool up in the back of the throat.The child should not receive anything orally when the child is seizing. The nurse should administer medications via intravenous push (IVP) or intramuscular (IM) during prolonged seizure activity.It is appropriate for the nurse to allow the child to sleep once the seizure has ended. The child should be placed in the left lateral recumbent recovery position.

The nurse has developed a nursing plan for the care of a 6-year-old girl with congenital hydrocephalus whose shunt has become infected. The most important discharge teaching point for this family is: establishing seizure precautions for the child. ensuring the parents know how to properly give antibiotics. encouraging development of motor skills. maintaining effective cerebral perfusion.

ensuring the parents know how to properly give antibiotics. Explanation: Educating parents how to properly give the antibiotics would be the priority intervention because the child's shunt has become infected. Maintaining cerebral perfusion is important for a child with hydrocephalus, but the priority intervention for the parents at this time concerns the infection. Establishing seizure precautions is an intervention for a child with a seizure disorder. Encouraging development of motor skills would be appropriate for a microcephalic child.

The nurse is using the pediatric Glasgow Coma Scale to assess a child's level of consciousness. What would the nurse assess? Select all that apply. eye opening verbal response motor response fontanels (fontanelles) posture

eye opening verbal response motor response Explanation: The pediatric Glasgow Coma Scale assesses level of consciousness using three parts: eye opening, verbal response, and motor response.

The nurse knows that the heads of infants and toddlers are large in proportion to their bodies, placing them at risk for what problem? congenital hydrocephalus positional plagiocephaly head trauma intracranial hemorrhaging

head trauma Explanation: A larger head size in relation to the rest of their body size gives young children a higher center of gravity, which causes them to hit their head more readily, thus placing them at risk for head trauma. Fragile capillaries in the periventricular area of the brain put preterm infants at risk for intracranial hemorrhage. Congenital hydrocephalus may be caused by abnormal intrauterine development or infection. Positional plagiocephaly is caused by an infant's head remaining in the same position for too long.

A nurse in the emergency department (ED) is assessing a 2-year-old male child. The parents state the child "has been very feverish the past few days, and today the child developed a purple rash on the chest. The child is now very sleepy." Click to highlight the findings that will require immediate follow-up. The assessment reveals the child is lethargic but opens eyes and answers yes and no to questions. The child is unable to lie with hips flexed and straighten the leg out , and states their neck hurts when trying to move it. Vital signs: temperature, 102.4°F (39.1°C) ; heart rate, 120 beats/min; blood pressure, 78/45 mm Hg; respirations, 28 breaths/min ; oxygen saturation, 92% on room air .

lethargic,unable to lie with hips flexed and straighten the leg out, neck hurts, 102.4°F (39.1°C), blood pressure, 78/45 mm Hg; respirations, 28 breaths/min, 92% on room air'Explanation: The client's temperature of 102.4°F (39.1°C) indicates a fever. This will require the nurse to follow up to determine the underlying cause for the fever. A purple (purpuric) rash appearing during a febrile state requires follow-up, because it may indicate meningitis. The child reporting a stiff neck may indicate meningeal irritation. The child's inability to straighten the leg when lying flat with hips flexed indicates meningeal irritation; it is referred to as a positive Kernig sign. Lethargy indicates decreased level of consciousness; the nurse should closely monitor the child's level of consciousness. The child's oxygen saturation of 92% on room air indicates decreased oxygen levels. The child's blood pressure of 78/45 mm Hg and respiratory rate of 28 breaths/min are within normal range for a 2-year-old child.

The nurse is assessing a child following a head injury sustained in a bicycle accident. The child falls asleep frequently unless the parents are talking to the child or the nurse is asking the child questions. How should the nurse document the child's level of consciousness? obtunded stupor fully conscious decreased level of consciousness

obtunded Explanation: Obtunded is defined as a state in which the child has limited responses to the environment and falls asleep unless stimulation is provided. Fully conscious describes a child who has no neurologic changes. Stupor exists when the child only responds to vigorous stimulation. Decreased level of consciousness is a vague term that does not describe the assessment findings.f

After experiencing a head injury the child keeps falling asleep when no one is rousing him. When documenting this in the medical record which term is most appropriate? lethargic unconscious obtunded stupor

obtunded Explanation: Obtunded is defined as a state in which the child has limited responses to the environment and falls asleep unless stimulation is provided. Stupor exists when the child only responds to vigorous stimulation. Lethargic refers to being without energy and relaxed.

A nurse is caring for an infant who has just undergone a ventricular tap. In what position should the nurse place the infant immediately after the procedure? high-Fowler position while sitting on the parent's lap semi-Fowler position with a parent at the bedside prone on the bed with a parent or caregiver on either side of the bed supine on a parent's lap

semi-Fowler position with a parent at the bedside Explanation: Proper positioning for an infant after a ventricular tap is to place the child in a semi-Fowler position to prevent additional drainage from the puncture site. Allow the parents or caregivers to comfort the child. Placing the child in the prone or supine position could allow for additional drainage from the puncture site. High-Fowler position is contraindicated immediately after this procedure.

A child is brought to the emergency department after experiencing a series of continuous seizures. The nurse is reviewing the orders for care and treatment. Which order would be of the highest priority? urinalysis hemoglobin level white blood cell count serum glucose level

serum glucose level Explanation: Status epilepticus is the occurrence of repetitive seizures in an individual. This is a neurological emergency. The events of the repetitive seizures greatly expend energy. This will result in rapid drops in serum glucose level, making this the priority laboratory value to review.

The nurse cares for a 7-year-old child with new-onset seizure disorder. Which prescription will the nurse anticipate for this client? vagus nerve stimulation frequent temperature assessment ketogenic diet use of anticonvulsant medications

use of anticonvulsant medications Explanation: Complete control of seizures can be achieved for most people through the use of anticonvulsant drug therapy. These medications are typically used first as treatment for seizure disorders. Frequent temperature assessment would only be useful in febrile seizures. Ketogenic diets (high in fat, low in carbohydrates, and adequate in protein) cause the child to have high levels of ketones, which help to reduce seizure activity. Diet is generally used when medications cannot control a child's seizure activity. Stimulating the left vagus nerve intermittently with electrical pulses may reduce seizure frequency. This requires surgically implanting a stimulator under the skin and is approved for children 12 and older.

The nurse is caring for a 3-year-old boy who is experiencing seizure activity. Which diagnostic test will determine the seizure area in the brain? cerebral angiography lumbar puncture video electroencephalogram computed tomography

video electroencephalogram Explanation: A video electroencephalogram can determine the precise localization of the seizure area in the brain. Cerebral angiography is used to diagnose vessel defects or space-occupying lesions. Lumbar puncture is used to diagnose hemorrhage, infection, or obstruction in the spinal canal. Computed tomography is used to diagnose congenital abnormalities such as neural tube defects.

The young child has been diagnosed with bacterial meningitis. Which nursing interventions are appropriate? Select all that apply. a) Identify close contacts of the child who will require post-exposure prophylactic medicationb) Initiate seizure precautionsc) Monitor the child for signs and symptoms associated with decreased intracranial pressured) Administer antibiotics as orderede) Initiate droplet isolation

• Initiate droplet isolation • Identify close contacts of the child who will require post-exposure prophylactic medication • Administer antibiotics as ordered • Initiate seizure precautions

The nurse is collecting data on an 18-month-old child admitted with a diagnosis of possible seizures. When interviewing the caregivers, which questions would be most important for the nurse to ask? "Has anyone in your family been sick recently" "Have you checked your child's temperature?" "Is your child up to date on his immunizations?" "What type of activities was your child doing today?"

"Have you checked your child's temperature?" Explanation: In children between the ages of 6 months and 3 years, febrile seizures (seizures resulting from fever) are the most common. Febrile seizures usually occur in the form of a generalized seizure early in the course of a fever. Although an illness in another member of the family might indicate the possibility of an infection or other illness, this would not be the priority question to ask. If the child has had an immunization recently, the child could develop a fever, but asking if the immunizations are up-to-date is not asking about recent immunizations. The child's daily activities would not likely promote seizure activity.

A 9-year-old boy is suffering from headaches but has no signs of physical or neurologic illness. Which intervention would be most appropriate? Teach the child and his parents to keep a headache diary. Have the parents call the doctor if the child vomits more than twice. Have the child sleep without a pillow under his head. Review the signs of increased intracranial pressure with parents.

Teach the child and his parents to keep a headache diary. Explanation: A headache diary can help identify any triggers so that the child can avoid them. Triggers can include foods eaten, amount of sleep the night before, or activities at home or school that might be causing stress. Reviewing signs of increased intracranial pressure would be inappropriate because increased intracranial pressure is not associated with headaches. Having the child sleep without a pillow is an intervention to reduce pain from meningitis. Vomiting more than twice is an indication that the parents should notify the physician or nurse practitioner when the child has a head injury.

The nurse is caring for an adolescent who suffered an injury during a diving accident. During assessment the client is demonstrating the posturing in the figure. The nurse is aware that this type of posturing is the result of injury to what area? cerebral cortex frontal lobe mid-cervical brain stem

brain stem Explanation: Decerebrate posturing is seen with injuries occurring at the level of the brain stem. Decorticate posturing occurs with damage of the cerebral cortex. Both types of posturing are characterized by extremely rigid muscle tone. Injuries to the frontal lobe of the brain and the mid-cervical spine would not cause these types of posturing.

The nurse caring for an infant with craniosynostosis, specifically positional plagiocephaly, should prioritize which activity? moving the infant's head every 2 hours measuring the intake and output every shift massaging the scalp gently every 4 hours giving the infant small feedings whenever he is fussy

moving the infant's head every 2 hours Explanation: Positional plagiocephaly can occur because the infant's head is allowed to stay in one position for too long. Because the bones of the skull are soft and moldable, they can become flattened if the head is allowed to remain in the same position for a long period of time. Massaging the scalp will not affect the skull. Measuring the intake and output is important but has no effect on the skull bones. Small feedings are indicated whenever an infant has increased intracranial pressure, but feeding an infant each time he fusses is inappropriate care.