Difficulty: Medium
Average Score: 62%
Simulated
The nurse is giving care to an infant with a brain tumor. The nurse observes the infant arch the back (see figure). The nurse should:
Correct answer
A
Rationale
The infant has opisthotonos, an indication of brain stem herniation; the nurse should notify the physician immediately and have resuscitation equipment ready. Stroking the back will not relieve the herniation or release the arching. Although the infant may also have a seizure, and padded side rails will prevent injury, the fi rst action is to notify the physician. Placing the child in a prone position will not relieve the herniation or release the arching.