NCLEX-PN Practice Q 196

By | February 27, 2022

A 5-month-old infant is admitted to the ER with a temperature of 106°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
  
     A. Negative scarf sign
     B. Positive Babinski reflex
     C. Tenseness of the anterior fontanel
     D. Periorbital edema
    
    

Correct Answer: C. Tenseness of the anterior fontanel

Option C: Bacterial meningitis is the inflammation of the meninges (membranes that cover the brain and spinal cord) caused by bacteria. The nurse should assess the infant with this condition for the tenseness of the anterior fontanel which may indicate an increase in intracranial pressure.

Option A: Negative scarf relates to the preterm infant, not the infant with meningitis.
Option B: Positive Babinski reflex is normal in the infant.
Option D: Periorbital edema is not associated with meningitis.

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