Senior Seminar Quiz 4 (Ch. 33-45)

The mother of a hospitalized 2year old child with viral laryngotracheobronchitis (croup) asks the nurse why the HCP did not prescribe abx. Which response should the nurse make?

"Abs are not indicated unless a bacterial infection is present."

Antibiotics are prescribed for a child with otitis media who underwent a myringotomy with insertion of tympanostomy tubes. The nurse provides discharge instructions to the parents regarding the administration of the abx. Which statement if made by the parents indicates an understanding of the instructions provided?

"Administer the abx until they are gone"

A child is placed in skeletal traction for txt of a fractured femur. The nurse creates a plan of care and should include which intv?

check the HCP's prescriptions for the amount of weight to be applied

The nurse is reviewing a txt plan with the parents of a newborn with hypospadias. Which statement by the parents indicates their understanding of the plan?

circumcision has been delayed to save tissue for surgical repair

a lumbar puncture is performed on a child suspected to have bacterial meningitis and CSF is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which result would verify the diagnosis?

cloudy CSF, elevated protein, and decreased glucose levels

On assessment of a child admitted with a diagnosis of acute stage kawasaki disease, the nurse expects to note which clinical manifestation of the acute stage of the disease?

conjunctival hyperemia

an infant of a mother infected with HIV is seen in the clinic each month and is being monitored for symptoms indicative of HIV infection. With knowledge of the most common opportunistic infection of children infected with HIV, the nurse assesses for which sign?

cough

The nurse is caring for an infant with a diagnosis of bladder exstrophy. To protect the exposed bladder tissue, the nurse should plan which intervention?

cover the bladder with nonadhering plastic wrap

A parent brings her 4 month old infant to a well baby clinic for immunizations. the child is up to date with the immunization schedule. the nurse should prepare to administed which immunizations to this infant?

DTap, Hib, IPV, PCV, RV

A child with B-thalassemia is receiving long-term blood transfusion therapy for the treatment of the disorder. Chelation therapy is prescribed as a result of too much iron from the transfusions. Which medication should the nurse anticipate to be prescribed

Deferoxamine

The nurse conducting staff in-service training on von Willebrand's disease. Which should the nurse include as characteristics of von Willebrand's disease?

Easy bruising occurs Gum bleeding occurs It is a hereditary bleeding disorder Tx and care are similar to that for hemophilia The disorder causes platelets to adhere to damaged endothelium

A school aged child with type 1 DM has soccer practice and the school nurse provides instructions regarding how to prevent hypoglycemia during practice. Which should the school nurse tell the child to do?

Eat a small box of raisins or drink a cup of orange juice before soccer practice

The mother of a 6year old child who has type 1 DM call a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action?

Encourage the child yo drink liquids

The nurse is caring for a newborn with a suspected dx of imperforate anus. The nurse monitors the infant, knowing that which is a clinical manifestation associated with this disorder?

Failure to pass meconium stool in the first 24 hours after birth

The mother of a 3year old child arrives at a clinic and tells the nurse that the child has been scratching the skin continuously and has developed a rash. The nurse assesses the child and suspects the presence of scabies. The nurse bases this suspicion on which finding noted on assessment of the child's skin?

Fine grayish red lines

The clinic nurse instructs parents of a child with sickle cell anemia about the precipitating factors related to sickle cell crisis. Which, if identified by the parents as a precipitating factor, indicates the need for further instruction?

Fluid overload

The clinic nurse reviews the record of an infant and notes that the HCP has documented a dx of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the mother to seek health care for the infant?

Foul smelling ribbon like stools

The nurse is caring for a child after a tonsillectomy. The nurse monitors the child, knowing that which finding indicates the child is bleeding?

Frequent swallowing

An adolescent client with type 1 DM is admitted to the ED for tx of DKA. Which assessment findings should the nurse expect to note?

Fruity breath odor and decreasing LOC

The nurse should implement which interventions for a child older than 2 years with type 1 DM who has a blood glucose level of 60 mg/dL?

Give child teaspoon of honey Prepare to administer glucagon SubQ if unconciousness occurs

a 4 yo child sustains a fall at home. after an xray, the child is determined to have a fractured arm and a plaster cast is applied. The nurse provides instructions to the parents regarding care for the child's cast. Which statement by the parents indicates a need for further instructions?

I can use lotion or powder around the cast edges to relieve itching

THe nurse is caring for a 4 yo child with HIV infection. THe nurse should expect which statement that is aligned with the psychosocial expectations of this age?

I know it hurts to die

a 6 yo child with HIV infection has been admitted to the hospital for pain managment. the child asks the nurse if the pain will ever go away. the nurse should make which response?

I know it must hurt, but if you tell me when it does I will try to make it hurt a little less

parents bring their 2 wk old infant to a clinic for txt after a diagnosis of clubfoot made at birth. Which statement made by the parents indicates a need for further instruction?

I need to bring my infant back to the clinic in 1 month for a new cast

the nurse is providing instructions to the parents of a child with scolosis regarding the use of a brace. Which statement by the parent indicates a need for further instruction?

I should apply lotion under the brace to prevent skin breakdown

the nurse is providing medication instruction to a parent. which statment by the parent indicates a need for further instruction

I should mix the med in the baby food and give it when I feed my child

THe home care nurse provides instructions regarding the basic infection control to the parent of an infant with HIV. Which statement, if made by the parent, indicates a need for further instruction?

I will clean up any spills from the diaper with diluted alcohol

A 10year old child with hemophilia A has slipped on the ice and bumped his knee. The nurse should prepare to administer which prescription?

IV infusion of factor VIII

The nurse provided discharge instructions to the parents of a 2 year old who had an orchiopexy to correct cryptochidism. Which statement by the parent indicated the need for further instruction?

Ill let him decided when to return to his play activities

A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The other becomes concerned because the child is frightened, consistently crying and trying to climb out of the tent. Which is the most appropriate nursing action?

Let the mother hold the child and direct the cool mist over the childs face

A child hospitalized because of persistent vomiting. The nurse should monitor the child closely for which problem?

Metabolic alkalosis

a child with type 1 DM is brought to the ED by mother who states that the child has been complaining of abd. pain and has been lethargic. DKA is dx. Anticipating the plan of care, the nurse prepares to administer which type of IV infusion?

Normal saline

The nurse is monitoring a child for bleeding after surgery for removal of a brain tumor. The nurse checks the head dressing for the presence of blood and notes a colorless drainage on the back of the dressing. Which intervention should the nurse perform immediately?

Notify the HCP

The nurse analyzes the lab results of a child with hemophilia. the nurse understands that which result will most likely be abnormal in this child?

PTT

The mother of a 4year old child tells the pediatric nurse that the childs abdomen seems to be swollen. During further assessment, the mother tells the nurse that the child is eating well and that the activity level of the child is unchanged. The nurse, suspecting the possibility of a Wilm's tumor, should avoid which during the physical assessment?

Palpating the abdomen for a mass

a 10 year old child with asthma is treated for acute exacerbation in the ED. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition?

decreased wheezing

The mother of an 8 year old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the right side and that ibuprofen is not effective. Which instruction should the nurse provide to the mother?

encourage the child to lie on the right side

The clinic nurse reviews the record of a child just seen by a health care provider and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder?

exercise intolerance

The nurse performing an admission assessment on a 2 year old who has been diagnosed with nephrotic syndrome notes that which most common characteristic is associated with this syndrome

generalized edema

The parents of a child with juvenile idiopathic arthritis call the clilnic nurse b/c the child is experiencing a painful exacerbation of the disease. The parents ask the nurse if the child can perform ROM exercises at this time. The nurse should make which response?

have the child perform simple isometric exercises during this time

The nurse analyzes the lab values of a child with leukemia who is receiving chemo. The nurse notes that the platelet count is 19,500. O the basis of this lab result, which intervention should the nurse include in the plan of care?

initiate bleeding precautions

A mother brings her 3 wk old infant to a clinic for phenylketonuria rescreening blood test. The test indicates a serum phenylalanine level of 1mg/dL. The nurse reviews this result and makes which interpretation?

it is negative

An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse should place the infant in which best position at this time?

left lateral position

a 1 month old infant is seen in the clinic and is diagnosed w developmental dysplasia of the hip. on assessment, the nurse understands that which finding should be noted in this condition

limited range of motion in the affected hip

The nurse is planning care for a child with acute bacterial meningitis. based on the mode of transmission of this infection, which precautionary intvn should be included in the plan of care?

maintain resp isolation precautions for at least 24 hrs after the initiation of antibiotics

The nurse notes documentation that a child is exhibiting an inability to flex the leg when the thigh is flexed anteriorly at the hip. which condition does the nurse suspect?

meningitis

The nurse is caring for an infant with bronchiolitis, and dx tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action?

move the infant to a room with another child with RSV

The nurse is assigned to care for an 8 yo child w a diagnosis of a basilar skull fracture. The nurse reviews the HCP's prescriptions and should contact the HCP to question which prescription?

nasotracheal suction as needed

A child has a right femur fracture caused by a motor vehicle crash and is placed in skin traction temporarily until surgery can be performed. during assessment, the nurse notes that the dorsalis pedis pulse is absent on the right foot. which action should the nurse take?

notify the HCP

A child undergoes surgical removal of a brain tumor. During the postop period, the nurse notes that the child is restless, the pulse rate is elevated, and the BP has decreased significantly from the baseline value. The nurse suspects that the child is in shock. Which is the most appropriate nursing action?

notify the HCP

a child who has undergone spinal fusion for scoliosis complains of abd discomfort and begins to have episodes of vomiting. On further assessment, the nurse notes abd distention. The nurse should take which action?

notify the HCP

The nurse is assisting a HCP examining a 3 wk old infant with developmental dysplasia of the hip. What test or sign should the nurse expect the HCP to assess?

ortolani's maneuver

a HCP prescribes lab studies for an infant of a woman positive for HIV. The nurse anticipates that which lab study will be prescribed for the infant?

p24 antigen assay

The nurse is performing an assessment on a child admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which assessment finding should the nurse expect to observe?

pallor, edema, anorexia, proteinuria

The clinic nurse reads the results of a tuberculin skin test (TST) on a 3 year old child. The results indicate an area of induration measuring 10 mm. The nurse should interpret these results as which finding?

positive

A 7 year old child is seen in a clinic, and the health care provider documents a diagnosis of primary nocturnal enuresis. The nurse should provide which info to the parents?

primary nocturnal enuresis is usually outgrown w/out therapeutic intervention

a child is diagnosed with reyes syndrome. THe nurse creates a nursing care plan for the child and should include which intv in the plan?

provide a quiet atmosphere with dimmed lighting

A child has been dx with acute otitis media of the right ear. Which interventions should the nurse include in the plan of care?

provide a soft diet administer ibuprofen for fever q4h as prescribed and PRN instruct the parents about the need to administer the prescribed abx for the full course of therapy

an infant with a diagnossi of hydrocephalus is scheduled for surgery. which is the priority nursing intv in the preop period?

reposition the infant frequently

The nurse is planning care for a child with hemolytic-uremic syndrome who has been anuric and willl be receiving pertioneal dialysis txt. The nurse should plan to implement which measure?

restrict fluids as prescribed

The nurse is reviewing the record of a child with increased ICP and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which charateristic of this type of posturing?

rigid extension and pronation of the arms and legs

The nurse is preparing to care for a child after a tonsillectomy. The nurse documents on the plan of care to place the child in which position?

side lying

The nurse creates a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which items need to be placed at the childs bedside?

suctioning equiptment and oxygen

The nurse is providing home care instructions to the parents of a 10yr old child with hemophilia. which sport activity should the nurse suggest for this child?

swimming

The nurse is monitoring an infant with congenital heart disease closely for signs of HF. The nurse should assess the infant for which early signs of HF?

tachycardia

The clinic nurse is instructing the parent of a child with HIV infection regarding immuninzations. THe nurse should provide which instructions to the parent?

the inactivated influenza vaccine will be given yearly

The nurse is creating a plan of care for a child who is at risk for seizures. Which intvs apply if the child has a seizure?

time the seizure stay with the child move furniture away from the child

The nurse prepares to administer an IM injection to a 4 month old infant. The nurse selects which best site to administer the injection?

vastus lateralis

The nurse is monitoring a 3year old child for s/sx of increased ICP after a craniotomy. The nurse plans to monitor for which early s/sx of increased ICP?

vomiting

the nurse provides home care instructions to the parents of a hospitalized child with pertusis who is in the convalescent stage and is being prepared for discharge. Which statement indicates a need for further teaching?

we need to maintain droplet precautions and a quiet enviornement for at least 2 wks

The nurse is closely monitoring the intake and output of an infant with HF who is receiving diuretic therapy. The nurse should use which most appropriate method to assess the urine output?

weighing diapers

A health care provider has prescribed O2 as needed for an infant with HF. In which situation should the nurse administer O2 to the infant?

when drawing blood for electrolye level testing

The nurse is performing an assessmet on a 10 year old child suspected to have Hodgkin's disease. Which assessment findings are specifically characteristic of this disease?

abdominal pain painless, firm, and movable adenopathy in cervical area

The nurse is instructing the parents of a child with iron deficiency anemia regarding the administration of a liquid oral iron supplement. Which instruction should the nurse tell the parents?

administer the iron through a straw

The nurse reviews the lab results for a child with a suspected diagnosis of rheumatic fever, knowing that which lab study would assist in confirming the diagnosis?

anti-strepolysin O titer

an infant receives a diptheria, tetanus, and Dtap immunization at a well-baby clinic. The parent returns home and calls the clinc to report that the infant has developed swelling and redness at the site of injection. which intv shhould the nurse suggest to the parents?

apply a cold pack to the injection site

the nurse provides home care instruction the the parents with a child with AIDS. which statement by the parents indicate a need for further instruction?

"I can send my child to daycare if he has a fever, as long as it is a low-grade"

The nurse reviews the record of a child who is suspected to have glomerulonephritis. Which statement by the childs parents should the nurse expect that is associated with this diagnosis

"I noticed his urine was the color of coca cola lately"

The nurse prepares a teaching plan for the mother of a child dx with bacterial conjunctivitis. Which, if stated by the mother, indicates a need for further teaching?

"It is okay to share towels and washcloths"

The school nurse has provided an instructional session about impetigo to parents of the children attending the school. Which statement, if made by a parent, indicates a need for further instruction?

"Lesions most often are located on the arms and chest"

The nurse provides a teaching session to the nursing staff regarding osteosarcoma. Which statement by a member of the nursing staff indicates a need for information?

"The child does not experience pain at the primary tumor site."

The clinic nurse is providing instructions to a parent of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement should the nurse make to the parent?

"The child will receive the recommended basic series of immunization along with a yearly flu vaccine."

A 6year old child with leukemia is hospitalized and is receiving combination chemo. Lab results indicate that the child is neutropenic, and protective isolation procedures are initiated. The grandmother of the child visits and brings a fresh bouquet of flowers picked form her garden, and asks the nurse for a vase for the flowers. Which response should the nurse provide to the grandmother?

"The flowers from your garden are beautiful, but should not be placed in the childs room at this time"

A child with rheumatic fever will be arriving to the nursing unit for admission. On admission assessment, the nurse should ask the parents which question to elicit assessment info specific to the development of rheumatic fever?

"did the child have a sore throat of fever w/in the last 2 months"

Which question should the nurse ask the parents of a child suspected of having glumrulonephritis

"has the child had a sore throat or a throat infection in the last few weeks"

The nurse has provided home care instructions to the parents of a child who is being discharged after cardiac surgery. Which statement made by the parents indicate a need for further instructions?

"i can apply lotion of powder to the incision if it is itchy"

The nurse provides home care instructions to the parents of a child with HF regarding the procedure for administration of digoxin. Which statement made by the parent indicated the need for further instruction?

"if my child vomits after medication administration, I will repeat the dose"

the mother with HIV brings her 10 month old infant for a routine check up.... The nurse should make which most appropriate response?

"most children affected with HIV develop symptoms within the first 9 mo of life, and some become symptomatic sometime for they are 3 years old"

The nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. which instructions should be included on the list

-keep small toys and sharp objects away from the cast -elevate the extremity on pillows -contact the HCP if the child compains of numbness or tingling

which home care instruction should the nurse provide to the parent of a child with AIDS?

-monitor the childs weight -frequent hand washing -the child should avoid exposure to other illnesses -clean up bodily fluid spills with bleach solution

the clinic nurse is assessing a child who is scheduled to receive a live virus vaccine. what are the general contraindications associated with recieving a live virus vaccine?

-the child had a previous anaphylactic reaction to the vaccine -the child has a disorder that caused a severely deficient immune syndrome

A HCP prescription reads "ampicillin sodium 125 mg IV every 6 hrs" the med label reads "when reconstituted with 7.4 ml of bacteriostatic water, the final concentraiton is 1 g/7.4 ml" the nurse prepares to draw up how many ml to administer 1 dose?

0.925 ml

penicillin G procaine, 1,000,000 units IM, is prescribed for a child with an infection. The nurse determined that the dose is prescribed sage. How many ml?

1.7 ml

sulfisozazole, 1 g orally twice a day, is prescribed...The medication label reads 500 mg-tablets. The nurse has determined that the dosage prescribed is safe. How many tablets per dose?

2 tablets

a pediatric client with ventricular septal defect repair is placed on maintenance dosage of digoxin. the dosage is 8 mcg/kg/day and the clients weight is 7.2 kg. How many mcg of digoxin to administed to the client at each dose?

28.8 mcg

Permethrin is prescribed for a child with a dianosis of scabies. The nurse should give which instruction to the parents regarding the use of this treatment?

Apply the lotion to cool, dry skin at least 30 minutes after bathing

The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury?

A delay in growth may occur after burn injury An immature immune system presents an increased risk of infection for infants and young children Infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults

Ten nurse is monitoring a child with burns during treatment for burn shock. Which assessment provides the most accurate guide to determine the adequacy of fluid resuscitation?

Adequacy of capillary filling

A topical corticosteroid is prescribed by the HCP for a child with atopic dermatitis (eczema). Which instruction should the nurse give the parent about applying the cream?

Apply a thin layer of cream and rub it into the area thoroughly

a new parent expresses concern to the nurse regarding SIDS. She asks the nurse how to position her new infant for sleep. In which position should the nurse tell the parent to place he infant?

Back rather than on the stomach

A 4year old child is admitted to the hospital for abdominal pain. The mother reports that the child has been pale and excessively tired and is bruising easily. On the physical examination, lymphadenopathy and hepatosplenomegaly are noted. Dx studies are being performed because acute lymphocytic leukemia is suspected. The nurse determines that which lab result confirms the dx?

Bone marrow biopsy showing blast cells

The nurse is preparing to care for a child with a dx of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented?

Bright red blood and mucus in the stools

A child has fluid volume deficit. The nurse performs an assessment and determines that the child is improving and the deficit is resolving if which finding is noted?

Cap refill less than 2 seconds

A HCP prescribes an IV soon of 5% dextrose and 0.45% NS of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription?

Checks the amount of urine output

Th nurse reviews the record of a newborn infant and notes that a dx of esophageal atresia with tracheoesophageal fistula is suspected. The nurse expects to note which most likely sign of this condition documented in the record?

Choking with feedings

The nurse is preparing for the admission of an infant with a dx of bronchiolitis caused by RSV. Which interventions should the nurse include in the plan of care?

Place the infant in a private room Ensure that nurses caring for the infant with RSV do not care for other high-risk children

The mother of a 6year old child arrives at a clinic because the child has been experiencing itchy, red, and swollen eyes. The nurse notes a discharge from the eyes and sends a culture to the laboratory for analysis. Chlamydial conjunctivitis is dx. On the basis of this dx, the nurse determines that which requires further investigation?

Possible sexual abuse

The nurse admits a child to the hospital with a dx of pyloric stenosis. On assessment, which data would the nurse expect to obtain when asking the parent about the child's sx?

Projectile vomiting

The nurse is reviewing the lab results for a child scheduled for a tonsillectomy. The nurse determines that which lab value is most significant to review?

Prothrombin Time

Which interventions should the nurse include when creating a care plan for a child with hepatitis?

Providing low fat, well balanced diet Teaching the child effective hand washing techniques Instructing the parents to avoid administering medications unless prescribed

Lab studies are performed for a child suspected to have iron deficiency anemia. The nurse reviews the lab results, knowing that which result indicates this type of anemia?

RBCs that are microcytic and hypochronic

Which specific nursing interventions are implemented in the care of a child with leukemia who is at risk fro infection?

Reduce exposure to environmental organisms Use strict aseptic technique for all procedures Ensure that anyone entering the child's room wears a mask

The nurse has just administered ibuprofen to a child with a temp. of 102F. The nurse should also take which action?

Remove excess clothing and blankets from the child.

Thenurse is reviewing a HCPs prescriptions for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Which prescriptions documented in the child's record should the nurse question?

Restrict fluid intake Give meperidine, 25mg IV every 4hours for pain

The nurse provides home care instructions to the parents of a child with celiac disease. The nurse should teach the parents to include which food item in the child's diet?

Rice

After a tonsillectomy, the nurse reviews the HCPs postoperative prescriptions. Which prescription should the nurse question?

Suction every 2 hours

The day care nurse is observing a 2year old child and suspects that the child may have strabismus. Which observation made by the nurse indicates the presence of this condition?

The child consistently tilts the head to see

The clinic nurse is reviewing the health care provider's prescription for a child who has been diagnosed with scabies. Lindane has been prescribed for the child. The nurse questions the prescription if which is in the child's record?

The child is 18 months old

The ED nurse is caring for a child dx with epiglottitis. In assessing the child, the nurse should monitor for which indication that the child may be experiencing airway obstruction?

The child is leaning forward, with the chin thrust out

A dx of hodgkins disease is suspected in a 12 year old child. several dx studies are performed to determine the presence of this disease. Which dx test result will confirm the dx of hodgkins disease?

The presence of Reed-Sternberg cells in the lymph nodes

The nurse provides feeding instructions to a parent of an infant dx with GERD. Which instruction should the nurse give to the parent to assist in reducing the episodes of emesis?

Thicken feedings by adding rice cereal to formula

After a tonsillectomy, a child begins to vomit bright red blood. The nurse should take which initial action?

Turn the client to the side

The school nurse is performing pediculosis capitis assessments. Which assessment finding indicates that a child has a "positive: head check?

White sacs attached to the hair shafts in the occipital area

The nursing student is presenting a clinical conference and discusses the cause of B-thalassemia. The nursing student informs the group that a child at greatest risk of developing this disorder is which of these?

a child of mediterranean descent

The parents of a child recently diagnosed with cerebral palsy ask the nurse about the limitations of the disorder. The nurse responds by explaining that the limitations occur as a result of which pathophysicological process?

a chronic disability characterized by impaired muscle movement and posture

A child is receiving a series of the hep B vaccine and arrives at the clinic with his parent of the 2nd dose. before administering the vaccine, the nurse should ask the child and parent about his history of a severe allergy to which substance?

a previous dose of Hep B vaccine or component

The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. When analyzing the results of the urinalysis, which should the nurse most likely expect to note?

bacteriuria

a mother arrives at the emergency department w her 5 yo child and states that the child fell off a bunk bed. A head injury is suspected. The nurse checks the childs airway status and assess the child for early and late signs of increased ICP. Which is a late sign?

bradycardia