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 A
Explanation
A. "I will continue to check his blood sugar two times every day."
Correct Explanation: This statement indicates a need for further instruction.
Explanation: A child with type 1 diabetes requires frequent blood sugar monitoring, especially during illness. Checking blood sugar only twice a day is not sufficient, especially when the child has an upper respiratory infection. Illness can impact blood sugar levels, so more frequent monitoring is necessary to ensure proper diabetes management.
B. "I will report a change in her breathing or any signs of confusion."
Incorrect Explanation: This statement shows awareness of potential complications and the need to monitor for them.
Explanation: Children with type 1 diabetes are at risk of diabetic ketoacidosis (DKA) when they are sick. Changes in breathing patterns and signs of confusion are symptoms of DKA. Reporting these symptoms is important, as it could indicate a serious diabetic complication.
C. "I will encourage her to drink half a cup of water or sugar-free fluid every 30 minutes."
Incorrect Explanation: This statement demonstrates proper fluid management, especially during illness.
Explanation: Encouraging the child to stay hydrated with sugar-free fluids is essential, particularly when the child has an upper respiratory infection. Proper hydration helps prevent dehydration, which can be more concerning for a child with diabetes.
D. "I will notify the doctor if her temperature is not controlled by acetaminophen."
Incorrect Explanation: This statement shows an understanding of the importance of managing fever in a child with diabetes.
Explanation: Children with diabetes can experience difficulty managing blood sugar levels when they're sick. Fever can exacerbate this issue. Using acetaminophen to control fever is appropriate, and notifying the doctor if fever persists is a responsible action.
Correct Answer is C
Explanation
A) Smokey brown urine:
This finding is not typically associated with nephrotic syndrome. Smokey brown urine might indicate the presence of blood in the urine, which can be seen in conditions such as hematuria or certain kidney infections.
B) Polyuria:
Polyuria refers to excessive urination and is not a primary characteristic of nephrotic syndrome. However, children with nephrotic syndrome may have decreased urine output due to the loss of fluid and proteins through the damaged kidney filters.
C) Facial edema:
Facial edema (swelling of the face) is a hallmark of nephrotic syndrome. The loss of albumin in the urine results in a decrease in oncotic pressure (a force that helps keep fluid in the blood vessels), leading to fluid accumulation in the interstitial spaces, including the face, ankles, and abdomen.
D) Hypertension:
Hypertension (high blood pressure) is not a typical finding of nephrotic syndrome itself. However, it's possible for kidney damage to lead to secondary hypertension. In nephrotic syndrome, low levels of albumin can trigger the renin-angiotensin-aldosterone system, which can contribute to increased blood pressure.
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