Difficulty: Medium
Average Score: 94%
Simulated
Passage / Scenario
The nurse is monitoring an infant for signs of increased intracranial pressure (ICP).Which are late signs of increased intracranial pressure (ICP) in an infant?
Correct answer
D
Rationale
The correct answer is D because Cheyne-Stokes respirations, which involve periods of deep breathing followed by periods of apnea, are late signs of increased ICP in infants. This pattern indicates severe brainstem dysfunction due to elevated pressure. The other choices are incorrect because A describes early signs of ICP, B is not associated with ICP, and C does not specifically indicate increased ICP in infants. Overall, recognizing Cheyne-Stokes respirations in an infant can prompt immediate intervention to address the underlying cause of increased ICP.