The nurse is doing a neurologic assessment on a 2-month-old ...

[evelyn o bentley]

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. How should the nurse interpret these findings?
 
  a. Neurologic health
  b. Severe brain damage
  c. Decorticate posturing
  d. Decerebrate posturing

Question 2

The nurse is closely monitoring a child who is unconscious after a fall and notices that the child suddenly has a fixed and dilated pupil. How should the nurse interpret this?
 
  a. Eye trauma
  b. Brain death
  c. Severe brainstem damage
  d. Neurosurgical emergency

[snackralk]

Answer to Question 1

ANS: A
Moro, tonic neck, and withdrawal reflexes are three reflexes that are present in a healthy 2-month-old infant and are expected in this age group.

Answer to Question 2

ANS: D
The sudden appearance of a fixed and dilated pupil(s) is a neurosurgical emergency. The nurse should immediately report this finding. Although a dilated pupil may be associated with eye trauma, this child has experienced a neurologic insult. One fixed and dilated pupil is not suggestive of brain death. Pinpoint pupils or fixed, bilateral pupils for more than 5 minutes are indicative of brainstem damage. The unilateral fixed and dilated pupil is suggestive of damage on the same side of the brain.