The nurse is monitoring an infant for signs of increased intracranial pressure (ICP). Which are late signs of increased intracranial pressure (ICP) in an infant? (Select all that apply.)
a. Tachycardia
b. Alteration in pupil size and reactivity
c. Increased motor response
d. Extension or flexion posturing
e. Cheyne-Stokes respirations
ANS: B, D, E
Late signs of ICP in an infant or child include bradycardia, alteration in pupil size and reactivity, decreased motor response, extension or flexion posturing, and Cheyne-Stokes respirations.
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