A nurse assesses an infant for signs of increased intracranial pressure. Which signs would lead the nurse to notify the rapid response team? (Select all that apply.)
A.
Bulging fontanels
B.
Change in LOC
C.
Irregular respirations
D.
Posturing
E.
Seizures
ANS: A, C, D
Bulging fontanels, irregular respirations, and posturing are among the late signs of increased intracranial pressure and would lead the nurse to intervene quickly by notifying the health-care provider or by activating the rapid response team. The other signs are early indicators of increased intracranial pressure.
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