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A nurse recognizes which physical assessment finding commonly seen in young children with cerebral palsy?

A.

Persistent primitive reflexes

B.

Normal muscle tone

C.

Symmetrical movements

D.

Normal gross motor skills

Answer and Explanation

The Correct Answer is A

A. Persistent primitive reflexes (such as the Moro, tonic neck, or grasp reflex) are a hallmark finding in young children with cerebral palsy. Normally, these reflexes disappear as the nervous system matures. Their persistence indicates delayed or abnormal neurological development, which is common in cerebral palsy.
B. Children with cerebral palsy often demonstrate abnormal muscle tone, which may be spastic (increased tone), hypotonic (low tone), or fluctuate between both. Normal tone is not expected.
C. Symmetrical, well-coordinated movements are typically impaired. Children may show asymmetry, abnormal posture, or involuntary movements.
D. Gross motor skill development is often delayed or abnormal due to impaired muscle coordination and tone.


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Related Questions

Correct Answer is A

Explanation

A. Bleeding is the most concerning complication after a tonsillectomy. Frequent swallowing, especially when not associated with eating or drinking, may indicate that the child is swallowing blood trickling down the throat. This can be life-threatening if not identified promptly. Nurses should closely monitor for this subtle but critical sign.
B. Dehydration may occur after tonsillectomy if the child avoids drinking due to pain, but it presents with dry mucous membranes, decreased urine output, or lethargy—not frequent swallowing.
C. Allergic reaction to medications may cause rash, swelling, or respiratory distress, but it does not typically present as frequent swallowing.
D. Infection may occur several days postoperatively with fever, pain, and foul odor, but frequent swallowing is not the hallmark sign.

Correct Answer is B

Explanation

A. Enterococcus can cause UTIs, especially in hospitalized or catheterized patients, but it is not the most common cause in otherwise healthy children.
B. Escherichia coli (E. coli) is by far the most common pathogen responsible for pediatric urinary tract infections. It accounts for approximately 80–90% of all UTIs in children. The bacteria originate from the gastrointestinal tract and ascend through the urethra into the urinary tract, making it the leading cause.
C. Pseudomonas aeruginosa is less common and usually associated with complicated UTIs, such as those in children with structural abnormalities, indwelling catheters, or immunocompromised states.
D. Klebsiella can also cause UTIs but occurs far less frequently compared to E. coli.

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