System-based pediatric neurologic and musculoskeletal condition assessment findings and priority interventions.
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- What is an early sign of increased intracranial pressure (ICP) in an infant?
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Bulging fontanel
- What is Cushing's triad, a late sign of increased ICP?
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Bradycardia, irregular respirations, and widened pulse pressure
- What eye finding is called the 'setting sun sign' in infants with increased ICP?
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Eyes deviate downward with sclera visible above the iris
- What is the classic symptom triad of bacterial meningitis in an older child?
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Fever, nuchal rigidity, and headache
- What does a positive Brudzinski sign indicate?
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Involuntary hip and knee flexion when the neck is flexed, suggesting meningeal irritation
- What does a positive Kernig sign indicate?
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Pain or resistance on knee extension when the hip is flexed, suggesting meningeal irritation
- What is the priority nursing action when bacterial meningitis is suspected in a child?
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Initiate droplet precautions/isolation immediately
- What test confirms a diagnosis of meningitis?
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Lumbar puncture with cerebrospinal fluid (CSF) analysis
- Febrile seizures typically occur in children within what age range?
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6 months to 5 years
- During a child's active seizure, what is the priority nursing action?
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Protect from injury, position side-lying, and never restrain or insert anything into the mouth
- How does spina bifida occulta typically present externally?
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No visible sac; may show a dimple or tuft of hair over the spine
- What distinguishes a myelomeningocele from other forms of spina bifida?
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The sac contains meninges, cerebrospinal fluid, and neural tissue
- How should the sac be protected preoperatively in a newborn with myelomeningocele?
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Cover with a sterile, moist, non-adherent dressing and position the infant prone
- Why are children with spina bifida at increased risk for a specific allergy?
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Latex allergy, due to repeated early and ongoing latex exposure from surgeries and catheterizations
- ____ in an infant is a key sign of hydrocephalus.
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Rapid head circumference growth