The nurse is doing a neurologic assessment on a 2-month-old infant after a car accident. Moro, tonic neck, and withdrawal reflexes are present. The nurse should recognize that these reflexes are:
Symptomatic of decorticate posturing
Symptomatic of decerebrate posturing
Indicators of severe brain damage
Normal Findings
The Correct Answer is D
Reflexes play a crucial role in evaluating the neurological status of infants.
Moro reflex: Also known as the startle reflex, the Moro reflex is a normal response in infants. It occurs when an infant is startled by a sudden noise or movement. The baby responds by extending their arms and legs, followed by a quick contraction. This reflex usually disappears around 4-6 months of age.
Tonic neck reflex (fencer's reflex): This reflex involves turning an infant's head to one side, causing the arm on that side to extend and the opposite arm to flex. It's a normal reflex that typically disappears around 4-6 months of age.
Withdrawal reflex: The withdrawal reflex is a normal response to a stimulus, such as touching a baby's foot with a cold object. The baby will pull their leg away in response to the stimulus.
Symptomatic of decorticate or decerebrate posturing (options A and B):
Decorticate and decerebrate posturing are abnormal postures seen in individuals with severe brain damage or injury. Decorticate posturing involves the arms being flexed and held close to the body, while decerebrate posturing involves the arms being extended and the wrists being pronated. These reflexes are typically indicative of significant neurological dysfunction and are not expected in a 2-month-old infant after a car accident.
Indicators of severe brain damage (option C):
The reflexes described (Moro, tonic neck, and withdrawal reflexes) are not indicative of severe brain damage in a 2-month-old infant. These reflexes are normal for an infant of this age and are part of their typical neurological development.
Normal findings (option D):
The reflexes described are normal findings in a 2-month-old infant and are expected as part of their developmental milestones.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Document intake and output:
Documenting intake and output is an important nursing task, but it is not the top priority in a suspected case of bacterial meningitis. Timely administration of antibiotics to treat the infection takes precedence over documentation of intake and output.
B) Administer antibiotics when available.
Explanation:
Bacterial meningitis is a serious and potentially life-threatening infection of the membranes covering the brain and spinal cord. Rapid administration of antibiotics is crucial to effectively treat the infection and prevent its spread. Delay in antibiotic administration can lead to worsening symptoms and complications. Therefore, getting the appropriate antibiotics to the child as soon as they are available is the nurse's priority.
C) Reduce environmental stimuli:
Reducing environmental stimuli can be helpful in managing symptoms and providing comfort to the child with meningitis, but it is not the priority action. The immediate concern in a suspected case of bacterial meningitis is to treat the infection.
D) Maintain seizure precaution:
While maintaining seizure precautions is important, especially if the child has a history of seizures, it is not the top priority in a suspected case of bacterial meningitis. Administering antibiotics to treat the infection and prevent its progression is the primary concern.
Correct Answer is C
Explanation
A. "We worry about surgery. Do you think we should investigate direct donation of blood?"
Explanation: This statement doesn't show a clear understanding of nephrotic syndrome. Nephrotic syndrome is a kidney disorder that involves the kidneys' ability to filter blood, but it doesn't typically involve blood donation or surgery related to that. Direct donation of blood is not relevant to the treatment or management of nephrotic syndrome.
B. "We'll have to encourage lots of liquids. Did you say about Biters per day?"
Explanation: This statement suggests a misunderstanding of nephrotic syndrome and its management. Encouraging lots of liquids is generally not a primary concern in nephrotic syndrome. In fact, excess fluid intake might be counterproductive, as it could worsen edema (swelling) that often occurs with this condition. Additionally, the term "Biters per day" doesn't seem relevant to nephrotic syndrome or its management.
C. "My child really likes chips and bologna. I guess we will have to find something else."
Explanation: This statement indicates an understanding of dietary considerations related to nephrotic syndrome. Nephrotic syndrome involves protein loss through the urine, which can lead to low protein levels in the blood. To address this, dietary changes are often recommended to include foods rich in protein. Avoiding high-sodium foods like chips and bologna is also important, as excessive sodium intake can contribute to fluid retention and worsen edema.
D. "We understand the need for antibiotics, hope they can be given orally."
Explanation: This statement doesn't relate to nephrotic syndrome or its management. Nephrotic syndrome primarily involves issues with kidney function and protein loss, and antibiotics are not a standard treatment for this condition. Antibiotics are used to treat infections, which can sometimes be a complication of nephrotic syndrome due to the immune system's vulnerability, but the statement doesn't focus on the understanding of the disease itself.
Correct Answer: C. "My child really likes chips and bologna. I guess we will have to find something else."
Explanation: This statement shows an understanding of the dietary changes needed for a child with nephrotic syndrome. It acknowledges the importance of adjusting the child's diet to include protein-rich foods and avoid high-sodium options, which aligns with the nutritional considerations for managing nephrotic syndrome.
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