Peds
Integumentary Problems
Integumentary Problems
The nurse is monitoring a child with burns during treatment. Which assessment provides the most accurate guide to determine the adequacy of fluid resuscitation?
1. Skin turgor
2. Level of edema at burn site
3. Adequacy of capillary filling
4. Amount of fluid tolerated in 24 hours
Answer: 3
Rationale: Parameters such as vital signs (especially heart rate), urinary output volume, adequacy of capillary filling, and state of sensorium determine adequacy of fluid resuscitation. Although options 1, 2, and 4 may provide some information related to fluid volume, in a burn injury, and from the options provided, adequacy of capillary filling is most accurate.
A 10-year-old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child would monitor for which sign, knowing that it indicates a worsening of the condition?
1. Warm, dry skin
2. Decreased wheezing
3. Pulse rate of 90 beats per minute
4. Respirations of 18 breaths per minute
Answer: 2
Rationale: Asthma is a chronic inflammatory disease of the airways. Decreased wheezing in a child with asthma may be interpreted incorrectly as a positive sign when it may actually signal an inability to move air. A “silent chest” is an ominous sign during an asthma episode. With treatment, increased wheezing actually may signal that the child’s condition is improving. Warm, dry skin indicates an improvement in the child’s condition, because the child is normally diaphoretic during exacerbation. The normal pulse rate in a 10-year-old is 70 to 110 beats per minute. The normal respiratory rate in a 10-year-old is 16 to 20 breaths per minute.
Test-Taking Strategy: Note the word worsening in the question. Options 3 and 4 can be eliminated because they are comparable or alike in that they are normal vital signs. From the remaining options, recall that a “silent chest” is an ominous sign during an asthma episode and indicates severe bronchial spasm or obstruction.
A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated primary health care provider’s prescription?
1. Endotracheal intubation
2. 100 units of NPH insulin
3. Intravenous infusion of normal saline
4. Intravenous infusion of sodium bicarbonate
Answer: 3
Rationale: The primary goal of treatment in hyperosmolar hyperglycemic syndrome (HHS) is to rehydrate the client to restore fluid volume and to correct electrolyte deficiency. Intravenous (IV) fluid replacement is similar to that administered in diabetic ketoacidosis (DKA) and begins with IV infusion of normal saline. Regular insulin, not NPH insulin, would be administered. The use of sodium bicarbonate to correct acidosis is avoided because it can precipitate a further drop in serum potassium levels. Intubation and mechanical ventilation are not required to treat HHS.
Test-Taking Strategy: Focus on the subject, treatment of HHS, and note the strategic word, immediately. If you can recall the treatment for DKA, you will be able to answer this question easily. Treatment for HHS is similar to the treatment for DKA and begins with rehydration.
A client with atrial fibrillation is receiving a continuous heparin infusion at 1000 units/hr. Which result would indicate to the nurse that the client is receiving a therapeutic dose?
1. Prothrombin time of 12.5 seconds
2. Activated partial thromboplastin time of 28 seconds
3. Activated partial thromboplastin time of 60 seconds
4. Activated partial thromboplastin time longer than 120 seconds
Answer: 3
Rationale: Common laboratory ranges for activated partial thromboplastin time (aPTT) are 30 to 40 seconds. Because the aPTT should be 1.5 to 2.5 times the normal value, the client’s aPTT would be considered therapeutic if it was 60 seconds. Prothrombin time assesses response to warfarin therapy.
Test-Taking Strategy: Focus on the subject, the therapeutic effect of heparin. Prothrombin time is eliminated because it assesses response to warfarin therapy. The aPTT of 28 seconds is eliminated because this result indicates that the client is receiving no therapeutic effect from the continuous heparin infusion. Finally, the aPTT greater than 120 seconds can be eliminated because this value is beyond the therapeutic range and the client is at risk for bleeding.
A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention would be implemented to alleviate the child’s fears?
1. Encourage the child’s parents to stay with the child.
2. Encourage play with other children of the same age.
3. Advise the family to visit only during the scheduled visiting hours.
4. Provide a private room, allowing the child to bring favorite toys from home.
Answer: 1
Rationale: Although the preschooler already may be spending some time away from parents at a day care center or preschool, illness adds a stressor that makes separation more difficult. The child may ask repeatedly when parents will be coming for a visit or may constantly want to call the parents. Options 3 and 4 increase stress related to separation anxiety. Option 2 is unrelated to the subject of the question; in addition, it may be inappropriate for a child who may be immunocompromised and at risk for infection.
Test-Taking Strategy: Note that the subject relates to the child’s fear. Options 3 and 4 will increase anxiety and fear further and should be eliminated. Bearing the subject of the question in mind and considering the child’s diagnosis will assist you in eliminating option 2.
The parent of a 3-year-old child arrives at a clinic and tells the nurse that the child has been scratching the skin continuously and has developed a rash. The nurse assesses the child and suspects the presence of scabies. The nurse bases this suspicion on which finding noted on assessment of the child’s skin?
1. Fine grayish red lines
2. Purple-colored lesions
3. Thick, honey-colored crusts
4. Clusters of fluid-filled vesicles
Answer: 1
Rationale: Scabies is a parasitic skin disorder caused by an infestation of Sarcoptes scabiei (itch mite). Scabies appears as burrows or fine, grayish red, threadlike lines. They may be difficult to see if they are obscured by excoriation and inflammation. Purple-colored lesions may indicate various disorders, including systemic conditions. Thick, honey-colored crusts are characteristic of impetigo or secondary infection in eczema. Clusters of fluid-filled vesicles are seen in herpesvirus infection.
Test-Taking Strategy: Focus on the subject, clinical manifestations of scabies. Think about the characteristic of this parasitic skin disorder. Recalling that scabies infestation produces burrows will assist in directing you to the correct option.
The parent of an 8-year-old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The parent tells the nurse that the child complains of discomfort on the right side and that ibuprofen is ineffective. Which instruction would the nurse provide to the parent?
1. Increase the dose of ibuprofen.
2. Increase the frequency of ibuprofen.
3. Encourage the child to lie on the left side.
4. Encourage the child to lie on the right side.
Answer: 4
Rationale: Pneumonia is an inflammation of the pulmonary parenchyma or alveoli, or both, caused by a virus, mycoplasmal agents, bacteria, or aspiration of foreign substances. Splinting of the affected side by lying on that side may decrease discomfort. It would be inappropriate to advise the parent to increase the dose or frequency of the ibuprofen. Lying on the left side would not be helpful in alleviating discomfort.
Test-Taking Strategy: Options 1 and 2 can be eliminated because they are comparable or alike. Recall that the nurse does not adjust the dose or frequency of medications. Recalling the principles related to splinting an incision in the postoperative client will assist in directing you to the correct option, because these principles can be applied in this situation.
An external insulin pump is prescribed for a client with diabetes mellitus. When the client asks the nurse about the functioning of the pump, the nurse bases the response on which information about the pump?
1. It is timed to release programmed doses of either short-duration or NPH insulin into the bloodstream at specific intervals.
2. It continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels.
3. It is surgically attached to the pancreas and infuses regular insulin into the pancreas. This releases insulin into the bloodstream.
4. It administers a small continuous dose of short-duration insulin subcutaneously. The client can self-administer an additional bolus dose from the pump before each meal.
Answer: 4
Rationale: An insulin pump provides a small continuous dose of short-duration (rapid- or short-acting) insulin subcutaneously throughout the day and night. The client can self-administer an additional bolus dose from the pump before each meal as needed. Short-duration insulin is used in an insulin pump. An external pump is not attached surgically to the pancreas.
Test-Taking Strategy: Focus on the subject, use of an insulin pump. Recalling that short-duration insulin is used in an insulin pump will assist in eliminating options 1 and 2. Noting the word external in the question will assist in eliminating option 3.
The nurse provides discharge instructions to a client with atrial fibrillation who is taking warfarin sodium. Which statement by the client reflects the need for further teaching?
1. “I will avoid alcohol consumption.”
2. “I will take coated aspirin for my headaches.”
3. “I will take my pills every day at the same time.”
4. “I have already called my family to pick up a MedicAlert bracelet.”
Answer: 2
Rationale: Aspirin-containing products need to be avoided when a client is taking this medication. Alcohol consumption needs to be avoided by a client taking warfarin sodium. Taking the prescribed medication at the same time each day increases client compliance. The MedicAlert bracelet provides health care personnel with emergency information.
Test-Taking Strategy: Note the strategic words, need for further teaching. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Recalling that warfarin is an anticoagulant and that coated aspirin is an aspirin-containing product will direct you to the correct option.
A 16-year-old client is admitted to the hospital for acute appendicitis, and an appendectomy is performed. Which nursing intervention is most appropriate to facilitate normal growth and development postoperatively?
1. Encourage the client to rest and read.
2. Encourage the parents to room in with the client.
3. Allow the family to bring in the client’s favorite computer games.
4. Allow the client to interact with others in their same age group.
Answer: 4
Rationale: Adolescents often are not sure whether they want their parents with them when they are hospitalized. Because of the importance of their peer group, separation from friends is a source of anxiety. Ideally, the members of the peer group will support their ill friend. Options 1, 2, and 3 isolate the client from the peer group.
Test-Taking Strategy: Note the strategic words, most appropriate. Consider the psychosocial needs of the adolescent, and remember that the peer group is very important. Options 1, 2, and 3 are comparable or alike in that they isolate the client from their own peer group.
Permethrin is prescribed for a child with a diagnosis of scabies. The nurse would give which instruction to the parents regarding the use of this treatment?
1. Apply the lotion to areas of the rash only.
2. Apply the lotion and leave it on for 6 hours.
3. Avoid putting clothes on the child over the lotion.
4. Apply the lotion to cool, dry skin at least 30 minutes after bathing.
Answer: 4
Rationale: Permethrin is massaged thoroughly and gently into all skin surfaces (not just the areas that have the rash) from the head to the soles of the feet. Care needs to be taken to avoid contact with the eyes. The lotion would not be applied until at least 30 minutes after bathing and would be applied only to cool, dry skin. The lotion would be kept on for 8 to 14 hours, and then the child would be given a bath. The child would be clothed during the 8 to 14 hours of treatment contact time.
Test-Taking Strategy: Option 3 can be eliminated because the child would be clothed. Eliminate option 1 next because of the closed-ended word “only” in this option. From the remaining options, recalling the procedure for the application of this lotion will direct you to the correct option.
A new parent expresses concern to the nurse regarding sudden infant death syndrome (SIDS). The parent asks the nurse how to position the new infant for sleep. In which position would the nurse tell the parent to place the infant?
1. Side or prone
2. Back or prone
3. Stomach with the face turned
4. Back rather than on the stomach
Answer: 4
Rationale: SIDS is the unexpected death of an apparently healthy infant younger than 1 year for whom an investigation of the death and a thorough autopsy fail to show an adequate cause of death. Several theories are proposed regarding the cause, but the exact cause is unknown. Nurses need to encourage parents to place the infant on the back (supine) for sleep. Infants in the prone position (on the stomach) may be unable to move their heads to the side, increasing the risk of suffocation. The infant may have the ability to turn to a prone position from the side-lying position.
A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings support this diagnosis? Select all that apply.
1.Increase in pH
2.Comatose state
3.Deep, rapid breathing
4.Decreased urine output
5.Elevated blood glucose level
Answer: 2, 3, 5
Rationale: Because of the profound deficiency of insulin associated with DKA, glucose cannot be used for energy and the body breaks down fat as a secondary source of energy. Ketones, which are acid by-products of fat metabolism, build up, and the client experiences a metabolic ketoacidosis. High serum glucose contributes to an osmotic diuresis and the client becomes severely dehydrated. If untreated, the client will become comatose due to severe dehydration, acidosis, and electrolyte imbalance. Kussmaul’s respirations, the deep rapid breathing associated with DKA, is a compensatory mechanism by the body. The body attempts to correct the acidotic state by blowing off carbon dioxide (CO2), which is an acid. In the absence of insulin, the client will experience severe hyperglycemia. Option 1 is incorrect, because in acidosis the pH would be low. Option 4 is incorrect because a high serum glucose will result in an osmotic diuresis and the client will experience polyuria.
Test-Taking Strategy: Focus on the subject, findings associated with DKA. Recall that the pathophysiology of DKA is the breakdown of fats for energy. The breakdown of fats leads to a state of acidosis. The high serum glucose contributes to an osmotic diuresis. Knowing the pathophysiology of DKA will aid in identification of the correct answers.
A client who is receiving digoxin daily has a serum potassium level of 3 mEq/L (3 mmol/L) and reports anorexia. The cardiologist prescribes a serum digoxin level to be done. Which level would the nurse recognize as being outside of the therapeutic range?
1. 0.5 ng/mL (0.63 nmol/L)
2. 0.8 ng/mL (1.02 nmol/L)
3. 0.9 ng/mL (1.14 nmol/L)
4. 2.2 ng/mL (2.8 nmol/L)
Answer: 4
Rationale: The optimal therapeutic range for digoxin is 0.5 to 2.0 ng/mL (0.63 to 2.56 nmol/L). If the client is experiencing symptoms such as anorexia and is experiencing hypokalemia as evidenced by a low potassium level, digoxin toxicity is a concern. Therefore, option 4 is correct because it is outside of the therapeutic level and elevated.
Test-Taking Strategy: Focus on the subject, a digoxin level outside of the therapeutic range. Additionally, determine if an abnormality exists. Note that the client is experiencing anorexia and has a low serum potassium level. Therefore, it is best to select the option that identifies the highest level. Recall that in hypokalemia, the client is at greater risk for digoxin toxicity.
Which car safety device should be used for a child who is 8 years old and 4 feet tall?
1. Seat belt
2. Booster seat
3. Rear-facing convertible seat
4. Front-facing convertible seat
Answer: 2
Rationale: All children whose weight or height is above the forward-facing limit for their car safety seat should use a belt-positioning booster seat until the vehicle seat belt fits properly, typically when they have reached 4 feet, 9 inches in height (145 cm) and are between 8 and 12 years of age. Infants should ride in a car in a semireclined, rear-facing position in an infant-only seat or a convertible seat until they weigh at least 20 pounds (9 kg) and are at least 1 year of age. The transition point for switching to the forward-facing position is defined by the manufacturer of the convertible car safety seat but is generally at a body weight of 9 kilograms (20 pounds) and 1 year of age.
Test-Taking Strategy: Focus on the subject, car safety, and note the age and height of the child to identify the appropriate safety device. Remember that children should remain in a booster seat until they are 8 to 12 years old and at least 4 feet, 9 inches (145 cm) tall.
The school nurse has provided an instructional session about impetigo to parents of the children attending the school. Which statement, if made by a parent, indicates a need for further instruction?
1. “It is extremely contagious.”
2. “It is most common in humid weather.”
3. “Lesions most often are located on the arms and chest.”
4. “It might show up in an area of broken skin, such as an insect bite.”
Answer: 3
Rationale: Impetigo is a contagious bacterial infection of the skin caused by group A streptococcus (GAS; Streptococcus pyogenes) and Staphylococcus aureus. Impetigo is most common during hot, humid summer months. Impetigo may begin in an area of broken skin, such as an insect bite or atopic dermatitis. Impetigo is extremely contagious. Lesions usually are located around the mouth and nose but may be present on the hands and extremities.
Test-Taking Strategy: Note the strategic words, need for further instruction. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Think about the pathophysiology associated with impetigo. Knowledge regarding the cause and manifestations of impetigo will direct you to the correct option.
The clinic nurse is providing instructions to the parent of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement would the nurse make to the parent?
1. “The immunization schedule will need to be altered.”
2. “The child should not receive any hepatitis vaccines.”
3. “The child will receive all of the immunizations except for the polio series.”
4. “The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination.”
Answer: 4
Rationale: Cystic fibrosis is a chronic multisystem disorder (autosomal recessive trait disorder) characterized by exocrine gland dysfunction. The mucus produced by the exocrine glands is abnormally thick, tenacious, and copious, causing obstruction of the small passageways of the affected organs, particularly in the respiratory, gastrointestinal, and reproductive systems. Adequately protecting children with cystic fibrosis from communicable diseases by immunization is essential. In addition to the basic series of immunizations, a yearly influenza immunization is recommended for children with cystic fibrosis. Options 1, 2, and 3 are incorrect.
Test-Taking Strategy: Eliminate options 1, 2, and 3 because they are comparable or alike, indicating that the immunization schedule will be adjusted in some way. Recalling the importance of protection from communicable diseases, particularly in children with a disorder such as cystic fibrosis, will assist in directing you to the correct option.
The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose needs to be taken if which symptoms develop? Select all that apply.
1.Polyuria
2.Shakiness
3.Palpitations
4.Blurred vision
5.Light-headedness
6.Fruity breath odor
Answer: 2, 3, 5
Rationale: Shakiness, palpitations, and light-headedness are signs/symptoms of hypoglycemia and would indicate the need for food or glucose. Polyuria, blurred vision, and a fruity breath odor are manifestations of hyperglycemia.
Test-Taking Strategy: Focus on the subject, the treatment of hypoglycemia. Think about its pathophysiology and the manifestations that occur. Recalling the signs and symptoms of hypoglycemia will direct you to the correct option.
A client is being treated with procainamide for a cardiac dysrhythmia. Following intravenous administration of the medication, the client complains of dizziness. Which intervention would the nurse implement first?
1. Obtain a 12-lead electrocardiogram.
2. Check the client’s fingerstick blood glucose level.
3. Auscultate the client’s apical pulse and blood pressure.
4. Measure the QRS interval duration on the rhythm strip.
Answer: 3
Rationale: Signs of toxicity from procainamide include confusion, dizziness, drowsiness, decreased urination, nausea, vomiting, and tachydysrhythmias. If the client complains of dizziness, the nurse would assess the vital signs first. Although measuring the QRS duration on the rhythm strip and obtaining a 12-lead electrocardiogram may be interventions, these would be done after the vital signs are taken. Dizziness directly following the procainamide indicates that the medication was the likely cause and needs to be addressed before assessing for other possible causes such as hypoglycemia.
Test-Taking Strategy: Note the strategic word, first. Also use the steps of the nursing process to answer correctly. Remember to always assess the client first, not the monitoring devices. Therefore, auscultating the apical pulse and taking the blood pressure are the first actions.
The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths per minute. On the basis of this finding, which action is most appropriate?
1. Administer oxygen.
2. Document the findings.
3. Notify the pediatrician.
4. Reassess the respiratory rate in 15 minutes.
Answer: 2
Rationale: The normal respiratory rate in a 12-month-old infant is 20 to 40 breaths per minute. The normal apical heart rate is 90 to 130 beats per minute, and the average blood pressure is 90/56 mm Hg. The nurse would document the findings.
Test-Taking Strategy: Focus on the data in the question and note the strategic words, most appropriate. Recalling the normal vital signs of an infant and noting that the respiratory rate identified in the question is within the normal range will direct you to the correct option.
The clinic nurse is reviewing the pediatrician’s prescription for a child who has been diagnosed with lice. Lindane shampoo has been prescribed for the child. The nurse questions the prescription if which is noted in the child’s record?
1. The child is 18 months old.
2. The child is being bottle-fed.
3. A sibling is using lindane for the treatment of lice.
4. The child has a history of frequent respiratory infections.
Answer: 1
Rationale: Lindane shampoo is a pediculicide product that may be prescribed to treat lice. It is contraindicated for children younger than 2 years because they have more permeable skin, and high systemic absorption may occur, placing the children at risk for central nervous system toxicity and seizures. Lindane shampoo also is used with caution in children between the ages of 2 and 10 years. Siblings and other household members can be treated simultaneously. Options 2 and 4 are unrelated to the use of lindane. Lindane is not recommended for use by a breast-feeding/chest-feeding parent because the medication is secreted into human milk.
Test-Taking Strategy: Focus on the subject, contraindications of lindane. Recall the concepts related to the treatment of an 18-month-old child, the body surface area of children, and medication administration. These concepts will direct you to the correct option.
The emergency department nurse is caring for a child diagnosed with epiglottitis. In assessing the child, the nurse would monitor for which indication that the child may be experiencing airway obstruction?
1. The child exhibits nasal flaring and bradycardia.
2. The child is leaning forward, with the chin thrust out.
3. The child has a low-grade fever and complains of a sore throat.
4. The child is leaning backward, supporting self with the hands and arms.
Answer: 2
Rationale: Epiglottitis is a bacterial form of croup. A primary concern is that it can progress to acute respiratory distress. Clinical manifestations suggestive of airway obstruction include tripod positioning (leaning forward while supported by arms, chin thrust out, mouth open), nasal flaring, the use of accessory muscles for breathing, and the presence of stridor. Option 4 is an incorrect position. Options 1 and 3 are incorrect because epiglottitis causes tachycardia and a high fever.
Test-Taking Strategy: Focus on the subject, manifestations of airway obstruction in a child with epiglottitis. Eliminate option 1 first, because tachycardia rather than bradycardia would occur in a child experiencing respiratory distress. Eliminate option 3 next, knowing that a high fever occurs with epiglottitis. From the remaining options, visualize the descriptions in each, and determine which position would best assist a child experiencing respiratory distress.
A client with diabetes mellitus demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. What is the appropriate intervention to decrease the client’s anxiety?
1. Administer a sedative.
2. Convey empathy, trust, and respect toward the client.
3. Ignore the signs and symptoms of anxiety, anticipating that they will soon disappear.
4. Make sure that the client is familiar with the correct medical terms to promote understanding of what is happening.
Answer: 2
Rationale: Anxiety is a subjective feeling of apprehension, uneasiness, or dread. The appropriate intervention is to address the client’s feelings related to the anxiety. Administering a sedative is not the most appropriate intervention and does not address the source of the client’s anxiety. The nurse should not ignore the client’s anxious feelings. Anxiety needs to be managed before meaningful client education can occur.
Test-Taking Strategy: Use therapeutic communication techniques to answer the question. Remember that the client’s feelings are the priority. Keeping this in mind will direct you easily to the correct option.
The nurse is monitoring a client with hypertension who is taking propranolol. Which assessment finding indicates a potential adverse complication associated with this medication?
1. Report of infrequent insomnia
2. Development of expiratory wheezes
3. A baseline blood pressure of 150/80 mm Hg followed by a blood pressure of 138/72 mm Hg after two doses of the medication
4. A baseline resting heart rate of 88 beats per minute followed by a resting heart rate of 72 beats per minute after two doses of the medication
Answer: 2
Rationale: Audible expiratory wheezes may indicate a serious adverse reaction, bronchospasm. Beta blockers may induce this reaction, particularly in clients with chronic obstructive pulmonary disease or asthma. Normal decreases in blood pressure and heart rate are expected. Insomnia is a frequent mild side effect and need to be monitored.
Test-Taking Strategy: Focus on the subject, a potential adverse complication. Eliminate options indicating a decrease in blood pressure and a decrease in heart rate first, because these are expected effects from the medication. Next, focusing on the subject will direct you to the correct option.
The nurse is monitoring a 3-month-old infant for signs of increased intracranial pressure. On palpation of the fontanels, the nurse notes that the anterior fontanel is soft and flat. On the basis of this finding, which nursing action is most appropriate?
1. Increase oral fluids.
2. Document the finding.
3. Notify the pediatrician.
4. Elevate the head of the bed to 90 degrees.
Answer: 2
Rationale: The anterior fontanel is diamond-shaped and located on the top of the head. The fontanel should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. The nurse would document the finding because it is normal. There is no useful reason to increase oral fluids, notify the pediatrician, or elevate the head of the bed to 90 degrees.
Test-Taking Strategy: Note the strategic words, most appropriate, and the words soft and flat. This should provide you with the clue that this is a normal finding. A bulging or tense fontanel may result from crying or increased intracranial pressure.