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 D
Explanation
A) Places the infant in a side-lying position:
Positioning is important in the care of an infant with myelomeningocele. The infant is usually placed in a prone (on the abdomen) position to prevent pressure on the sac and protect the neural tissue. Placing the infant in a side-lying position may not provide the needed protection.
B) Maintains a dry dressing over the sac:
The sac should be kept moist with a sterile, non-adherent dressing moistened with saline to prevent drying and cracking, which could lead to infection.
C) Performs range of motion on the infant's hips:
Infants with myelomeningocele often have flaccid paralysis below the lesion, and excessive manipulation of the lower limbs could cause injury.
D) Takes an axillary temperature:
Rectal temperatures should never be taken, as they can cause mucosal damage or irritate the exposed spinal cord, leading to complications like meningitis. The axillary route is the safest method for temperature assessment.
Correct Answer is D
Explanation
A. Elevated blood glucose is remarkable with Cushing's Triad:
Elevated blood glucose is not one of the components of Cushing's Triad. The triad focuses on cardiovascular and respiratory changes associated with increased intracranial pressure, not blood glucose levels.
B. Cushing's Triad includes a positive Macawen's sign:
Macawen's sign is not part of Cushing's Triad. Cushing's Triad is specifically related to the physiological responses seen in response to increased intracranial pressure and is not associated with Macawen's sign.
C. Cushing's Triad includes tachycardia, seizures and rapid respirations:
This option is not accurate. Cushing's Triad involves bradycardia (slow heart rate), irregular respirations, and a widening pulse pressure. Tachycardia (rapid heart rate) and seizures are not part of Cushing's Triad but might be indicative of other medical conditions or complications.
D. Bradycardia, irregular respirations and a widening pulse pressure.
Explanation: Cushing's Triad is a set of three clinical signs that are indicative of increased intracranial pressure (ICP) and are considered ominous as they suggest serious brain injury or pathology. The triad consists of:
Bradycardia: This refers to a slow heart rate. As intracranial pressure increases, it can lead to a decreased heart rate due to pressure on the brainstem, which is involved in regulating heart rate.
Irregular Respirations: Increased ICP can affect the brainstem's control over breathing, leading to irregular patterns of breathing, often known as Cheyne-Stokes respiration. This is characterized by periods of rapid breathing followed by apnea (temporary cessation of breathing).
Widening Pulse Pressure: Pulse pressure is the difference between systolic and diastolic blood pressure. An increase in ICP can cause an increase in systolic blood pressure and a decrease in diastolic blood pressure, leading to a widening pulse pressure.
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