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 A
Explanation
A. Levothyroxine
Correct Answer: Levothyroxine should be administered before breakfast.
Explanation: Levothyroxine is a synthetic thyroid hormone used to treat hypothyroidism. It needs to be taken on an empty stomach, at least 30 minutes before eating, to ensure proper absorption. Food can interfere with its absorption, especially foods containing calcium, iron, and fiber.
B. Digoxin
Incorrect Explanation: Digoxin does not need to be administered before breakfast.
Explanation: Digoxin is a medication used to treat heart conditions like congestive heart failure and atrial fibrillation. It doesn't have specific instructions regarding administration in relation to meals. It's important to administer digoxin consistently at the same time every day, but it doesn't need to be taken specifically before or after breakfast.
C. Divalproex
Incorrect Explanation: Divalproex does not need to be administered before breakfast.
Explanation: Divalproex is used to treat conditions like epilepsy and bipolar disorder. It can be taken with or without food. While taking it with food might reduce the likelihood of stomach upset, there's no requirement to take it specifically before breakfast.
D. Mycostatin Mouthwash
Incorrect Explanation: Mycostatin mouthwash is not related to breakfast timing.
Explanation: Mycostatin is an antifungal medication used to treat fungal infections in the mouth (oral thrush). Its administration is not linked to meal times. It's typically swished around in the mouth and then swallowed or spit out, depending on the specific instructions provided by the healthcare provider.
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