The clinic nurse performs assessments on four infants. The nurse should alert the health care provider to see which client first?

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11ecbb05_caeb_bc9c_b433_9fbbd1508312_MD0009_00 Hydrocephalus is an increase in intracranial pressure (ICP) that results from obstruction of cerebrospinal fluid flow. Increased ICP can progress to brain damage and death. Signs of increased ICP in children include bulging fontanelles, increasing head circumference, and sunset eyes (or setting-sun sign) (sclera visible above the iris). Sunset eyes occur when periaqueductal structures are compressed from increased ICP, paralyzing the upward gaze. This is a late sign of increased ICP that requires timely treatment (eg, shunt placement) and is the priority (Option B). (Option A) Positional plagiocephaly (flat head syndrome) occurs when an infant is placed in the same position (eg, supine) for an extended period of time and the pliable skull molds to the surface (flattens). Parents can intervene to avoid or correct plagiocephaly (eg, periodically repositioning the head during sleep, tummy time). Minor skull deformation is not a priority. (Option C) Eight wet diapers in 24 hours is within the normal range (6-10 diapers/day or approximately 1 diaper every 4 hours), indicating that the infant is likely producing >1 mL/kg/hr urine output and is not dehydrated, despite vomiting. (Option D) The Babinski reflex (ie, toes fan outward and the big toe dorsiflexes with stimuli) is expected in infants and is a normal finding up to age 1 year. However, its presence beyond this age can indicate neurologic disease. Educational objective: The presence of sunset eyes (sclera visible above the iris) is a late sign of increased intracranial pressure and a priority to report to the health care provider.

The Clinic Nurse Performs Assessments on Four Infants