Bennett was rushed to the emergency department with possible increased intracranial pressure (ICP); which of the following is an early clinical manifestation of increased ICP in older children? (Select all that apply.)

Correct Answer: C

Rationale: Papilledema is a common early clinical manifestation of increased intracranial pressure (ICP) in older children. Papilledema is defined as optic disc swelling due to increased ICP transmitted to the optic nerve sheath. This can be visualized during a fundoscopic examination. It is important to identify papilledema promptly as it may signify increased ICP, which requires urgent evaluation and management to prevent potential complications. While other signs like Macewen's sign, Setting sun sign, and Diplopia can also indicate increased ICP, papilledema is a more specific sign seen in older children.

Correct Answer: B

Rationale: Flaring of nares in a newborn is typically interpreted as a sign of respiratory distress. When a baby is having trouble breathing or is not getting enough oxygen, the body compensates by increasing the size of the nasal passages to allow for easier airflow. This response helps the baby to breathe more effectively during times of respiratory distress. It is important for healthcare providers to recognize this sign as it may indicate the need for prompt intervention and support to help the baby breathe more comfortably.

Correct Answer: A

Rationale: Meconium is the term used to describe the first stool of a newborn. This stool is black and tarry in appearance. Meconium is made up of materials ingested by the fetus while in the uterus, such as mucus, amniotic fluid, and cells shed from the stomach and intestines. It is typically passed by a newborn within the first few days of life before transitioning to transitional stools, which are greenish-brown in color, and eventually to normal milk stools as the baby starts feeding on breast milk or formula.

Correct Answer: B

Rationale: The nurse can examine the client for stiffness and rigidity of the neck by moving the head and chin of the client toward the chest. This maneuver, known as neck flexion, assesses the resistance and presence of stiffness in the neck muscles. Stiffness and rigidity of the neck muscles may suggest conditions such as meningitis, cervical dystonia, or other neurologic disorders. It is important for the nurse to perform this examination maneuver carefully to avoid causing discomfort or injury to the client.

Correct Answer: C

Rationale: Lean red meats are a great source of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based sources. Heme iron from animal products is particularly beneficial for individuals with iron deficiency anemia as it can help increase their iron levels more effectively. In addition to lean red meats, other animal sources of heme iron include poultry and fish.