An infant born with spina bifida with a repaired myelomeningocele is brought the emergency department, where the parents report that the infant is very fussy and is feeding poorly. Which nursing action takes priority?
A.
Assess the baby's fontanels for bulging.
B.
Attach a cardiac and respiratory monitor.
C.
Obtain and document the baby's vital signs.
D.
Try feeding the baby with sucrose water.
ANS: A
Poor feeding and irritability are signs of increased intracranial pressure (ICP) in infants. A child with spina bifida is at risk for hydrocephalus, which can lead to increased ICP. A corroborating sign would be bulging fontanels. The nurse should quickly palpate the infant's fontanels. Monitoring the child and obtaining vital signs are important actions too, but palpating the fontanels can be done quickly as the nurse handles the child and performs other procedures. The nurse should not attempt to feed this baby now.
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Fill in the blank(s) with the appropriate word(s).
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