The nurse concerned about increased intracranial pressure in an infant should assess for which sign?

• A. Photophobia
• B. Irritability
• C. Pulsating anterior fontanel
• D. Vomiting and diarrhea

Answer: (B)

In infants, signs of increased intracranial pressure are conveyed through behavior and nonverbal cues rather than reported symptoms. Irritability is a key indicator because the infant cannot describe pain; when ICP rises, the baby often becomes fussy, inconsolable, and difficult to soothe, and feeding may be poor as distress increases.

Photophobia is not typically assessable or recognized in infants. A pulsating anterior fontanel can occur, but it is not a reliable or specific sign of ICP on its own. Vomiting can accompany elevated ICP, but diarrhea is not related to ICP elevations. So the presentation most consistent with increased ICP in an infant is irritability.