A nurse is caring for a child following surgical removal of a brain tumor. The nurse is monitoring the child and notes that the pulse rate has increased and the blood pressure has dropped significantly. Bloody drainage is also noted on the posterior dressing. The initial nursing action is to:
Correct Answer: D
Rationale: Increased pulse, low BP, and bloody drainage suggest hemorrhage or ICP; notify RN (D) immediately. Waiting (A), Trendelenburg (B), or documenting only (C) delays care. Document: 'Most tumors create increased ICP… [requiring] immediate action.'