The nurse assesses 4 children in the clinic. Which assessment finding requires the nurse's priority action?

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11ecbb05_cbd7_2dba_b433_e3dea2c5636f_MD0009_00 Infants with underlying infection and increased intracranial pressure (ICP) will be very irritable and have fever and a high-pitched cry. Other signs of increased ICP include changes in pupillary reaction, sunset eyes, dilated scalp veins, poor feeding, vomiting, and bulging fontanelles. The 3-month-old needs to be seen first due to the potential for bacterial meningitis. If bacterial meningitis is suspected, droplet precautions should be initiated and the infant should be treated with antibiotics immediately. (Option B) The absence of tears when crying indicates moderate dehydration. This infant needs evaluation but is not the priority. (Option C) In children under age 6 years, the diaphragm is the major respiratory muscle. This infant is displaying normal respiratory effort. Furthermore, cold symptoms are common in children. (Option D) Separation anxiety (distress when the primary caregiver is absent) is common in this age group (age 8 months to 2 years). Educational objective: Fever, vomiting, irritability, and a high-pitched cry may indicate serious underlying infection and increased intracranial pressure (ICP). An infant displaying signs of increased ICP requires further assessment immediately. Suspected bacterial meningitis necessitates prompt initiation of droplet precautions and antibiotics.

The Nurse Assesses 4 Children in the Clinic