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:

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.

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.