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학습 자료 둘러보기 →In a child with suspected meningitis, the most ominous finding is a bulging fontanelle combined with a high-pitched cry. This indicates a critical, late-stage rise in intracranial pressure (ICP). The anterior fontanelle should be closed by 18 months; its bulging in a 3-year-old suggests the pressure is forcing cranial sutures apart.
This finding signals an imminent risk of brainstem herniation and must be prioritized over classic signs like fever, photophobia, or neck stiffness. Immediate nursing actions include notifying the provider, preparing for airway management, and avoiding interventions that further increase ICP.
Do not perform a lumbar puncture if signs of critically elevated ICP are present without prior neuroimaging, as the sudden pressure shift can cause fatal herniation.
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