A mother brings her 11-month-old into the clinic. The infant exhibits the Moro reflex and cannot roll from front to back. The nurse understands that these signs can indicate:
myasthenia gravis.
spina bifida.
cerebral palsy.
Reye's syndrome.
The Correct Answer is C
Rationale:
A. Myasthenia gravis typically presents with muscle weakness and fatigue, but it does not usually cause retained primitive reflexes like the Moro reflex. It is also rare in infants.
B. Spina bifida can result in motor deficits, but the persistence of the Moro reflex is more commonly associated with cerebral palsy than with spinal defects.
C. The persistence of primitive reflexes (such as the Moro reflex beyond 6 months) and delayed gross motor milestones like rolling over are classic signs of cerebral palsy.
D. Reye's syndrome is an acute condition linked to aspirin use in viral infections. It causes liver dysfunction and encephalopathy, not developmental delays or retained reflexes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Bruising around the hip is not a typical sign of developmental dysplasia of the hip (DDH); it could indicate trauma.
B. Low urine output is unrelated to hip development and may indicate kidney or hydration issues.
C. Asymmetry in thigh or gluteal skin folds — such as extra skin folds on one leg — is a common sign of DDH. It suggests that the hip may not be properly aligned or developed.
D. Diaper fit can vary for many reasons and is not a reliable indicator of DDH.
Correct Answer is A
Explanation
Rationale:
A. The treatment and healing process for Legg-Calvé-Perthes disease typically takes months to years, not just six weeks. This statement reflects a misunderstanding and indicates the need for further education.
B. Swimming is a low-impact activity that helps maintain joint mobility and muscle strength without putting stress on the hip.
C. Monitoring skin integrity is important to prevent pressure sores from braces or orthotic devices.
D. Maintaining abduction of the affected leg helps keep the femoral head properly positioned in the hip socket, which is important in treatment.
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