Unformatted text preview: erence should be measured to obtain a baseline. Options 1, 2, and 3 are incorrect
because pulse rate will not be affected with this disorder, the specific gravity can indicate hydration status but it is not priority at
this time, and abdominal masses do not occur with this disorder.
54. Increased Intracranial Pressure
Late signs of increased intracranial pressure (ICP) include a significant decrease in level of
consciousness, bradycardia, and fixed and dilated pupils. A bulging fontanel and dilated scalp veins are early signs of increased
ICP and would be noted in an infant, not a 5-year-old child. Nausea is an early sign of increased ICP
55. Seizures During a seizure, the child is placed on his or her side in a lateral position. Positioning on the side will prevent
aspiration because saliva will drain out the corner of the child¶s mouth. The child is not restrained because this could cause injury
to the child. The nurse would loosen clothing around the child¶s neck and ensure a patent airway. Nothing is placed into the
child¶s mouth during a seizure because this action...
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- Spring '14
- Sudden infant death syndrome, Shaken baby syndrome