Practice Question
A nurse is caring for an infant in the emergency department.
Answer Choices:
Correct Answer:
Stabilize the infant's spine.
Rationale:
🔸 A. Stabilize the infant's spine:
✔️ In any trauma involving a fall—especially in infants—cervical spine injury must be ruled out.
✔️ Immobilization is critical until spinal cord injury is excluded to prevent neurological compromise.
✔️ This is especially important given the mechanism of injury (fall down stairs) and signs of altered consciousness.
🔸 B. Palpate fontanel level:
✔️ The anterior fontanel in infants offers a noninvasive means of assessing intracranial pressure (ICP).
✔️ A bulging or tense fontanel may indicate increased ICP, while a sunken fontanel suggests dehydration.
✔️ Monitoring this helps detect neurological deterioration in cases like subdural hematoma.
🔸 C. Assess pupillary reaction to light:
✔️ Pupillary response provides essential information on brainstem function and intracranial pressure.
✔️ Changes in pupil size, symmetry, or reactivity may signal brain herniation or deterioration.
✔️ This is a priority neuro check in any infant with head trauma.
🔸 E. Measure the infant's head circumference:
✔️ In infants, head circumference helps identify swelling, hydrocephalus, or hematoma expansion.
✔️ Monitoring trends in head size can be critical for detecting gradual increases in ICP.
✔️ This is especially important with subdural bleeds, where pressure can build over time.
🔸 F. Evaluate for the presence of a Babinski reflex:
✔️ The Babinski reflex is a neurologic assessment that helps evaluate cortical and spinal cord function.
✔️ An absent or asymmetric reflex may signal central nervous system damage.
✔️ In infants, the Babinski should be positive (toes fan out) until ~1 year—any deviation from normal should be assessed.
Want to practice more questions like this?
This question is from RN ATI Nur 2708 Pediatrics Final Exam which contains 51 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Pediatrics
- Answer Choices: 6