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) A step-wise approach will be used to reduce the dosage gradually.
Explanation:
After a certain period of seizure control, a healthcare provider may consider gradually tapering and discontinuing anti-seizure medications in consultation with the child's neurologist. This is often done in a step-wise manner to monitor the child's condition and minimize the risk of seizure recurrence. Stopping anti-seizure medications abruptly can increase the risk of seizures returning. Therefore, the response provided in option A is the most accurate and relevant to the situation.
The other options are incorrect:
B) Your child will always suffer seizures:
This statement is not accurate, as some children with epilepsy can achieve long-term seizure control with appropriate treatment. Epilepsy management varies from person to person, and many individuals can experience extended periods of seizure freedom.
C) This is always a hereditary disorder:
Epilepsy can have both genetic and non-genetic causes. While there are genetic forms of epilepsy, not all cases are hereditary. Epilepsy can be caused by a variety of factors, including brain injuries, infections, and other medical conditions.
D) Only her male offspring will experience seizures:
Epilepsy does not discriminate based on gender. Both males and females can be affected by epilepsy. This statement is not accurate and does not reflect the reality of epilepsy as a medical condition.
Correct Answer is D
Explanation
A) Kidneys are very small and irregular.
Explanation: This statement is not the primary reason for instructing caregivers about preventing kidney injury in babies or children under 2 years old. While it is true that infant and toddler kidneys are relatively smaller and have a slightly different shape compared to adult kidneys, the main concern for kidney injury prevention in this age group is related to other factors.
B) The occurrence of Hirsutism.
Explanation: Hirsutism refers to excessive hair growth, typically in a male pattern, in women and children. It is not directly related to kidney injury prevention in babies or children under 2 years old. Hirsutism is usually caused by hormonal imbalances and is not a primary consideration when instructing caregivers about preventing kidney injury.
C) Diaper rashes.
Explanation: Diaper rashes are skin irritations that occur in the diaper area of infants and young children. While diaper rashes can be uncomfortable and require proper care, they are not a major concern when instructing caregivers about preventing kidney injury. Diaper rashes are typically a result of prolonged exposure to moisture and can be managed with good hygiene practices and appropriate diaper-changing routines.
D) Children under two years old are more vulnerable to kidney trauma from compression force to abdomen.
Explanation: This statement is true and is the main reason for instructing caregivers about preventing kidney injury in babies or children under 2 years old. Children in this age group have relatively larger abdomens and less developed abdominal muscles, which makes their kidneys more susceptible to injury from compression forces to the abdomen. This is why caregivers are advised to handle young children carefully, avoid rough play, and ensure that they are securely fastened in car seats and other safety devices to prevent potential kidney trauma.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today