ATI RN
ATI Pediatrics Exam Simmons U BSN Questions
Extract:
A 2-month-old infant after a car accident
Question 1 of 5
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:
Correct Answer: D
Rationale: The correct answer is D: Normal Findings. At 2 months old, Moro, tonic neck, and withdrawal reflexes are normal developmental reflexes. Moro reflex is an involuntary response to sudden movements or loud noises; tonic neck reflex occurs when the head is turned to one side, causing the arm on that side to extend and the opposite arm to flex; withdrawal reflex is a protective response to noxious stimuli. These reflexes are part of the infant's primitive reflexes and are expected to be present at this age.
Choices A and B are incorrect as decorticate and decerebrate posturing are abnormal motor responses indicating brain injury.
Choice C is incorrect as the presence of these reflexes does not necessarily indicate severe brain damage in a 2-month-old infant.
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Question 2 of 5
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Question 4 of 5
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Question 5 of 5
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