Question 1 of 6
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Which reflexes should the nurse assess to evaluate CNs II, III, IV, and VI in infants?
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- Rooting reflexThe rooting reflex should be assessed to evaluate CN V, not to evaluate CNs II, III, IV, and VI.
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- Swallowing reflexThe swallowing reflex should be assessed to evaluate CNs IX and X, not CNs II, III, IV, and VI.
- Correct
- Optical blink reflexThe optical blink reflex should be assessed to evaluate CNs II, III, IV, and VI in infants.
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- Acoustic blink reflexThe acoustic blink reflex should be assessed to evaluate CN III, not CN II, III, IV, and VI.
Question 2 of 6
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The nurse would shine a light in an infant’s open eyes to assess which cranial nerve?
- Correct
- CN IIThe nurse would shine a light in the infant’s eyes and observe for a quick eye closure and dorsal flexion of the head to assess CN II.
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- CN VTo assess CN V, the nurse should touch the corner of the infant’s mouth or put one finger in the mouth, not shine a light in the infant’s eyes.
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- CN VIITo assess CN VII, the nurse should observe the infant’s face while he or she is crying, not shine a light in the infant’s eyes.
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- CN XTo assess CN X, the nurse should assess the swallowing and gag reflexes, not shine a light in the infant’s eyes.
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- CN XIITo assess CN XII, the nurse should pinch the infant’s nose, not shine a light in the infant’s eyes.
Question 3 of 6
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In which way would a nurse evaluate CN VII in an infant?
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- Pinch the infant’s noseThe nurse should pinch the infant’s nose to assess CN XII, not to assess CN VII.
- Correct
- Observe the infant while cryingThe nurse should observe the infant’s facial expression while the infant is crying to assess CN VII.
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- Shine a light in the infant’s eyesThe nurse would shine a light in the infant’s eyes to assess CNs VII, III, IV, and VI, not CN VII.
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- Touch one corner of the infant’s mouthThe nurse would touch one corner of the infant’s mouth to assess CN V, not CN VII.
Question 4 of 6
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Match the primitive reflex with the age at which it should be assessed.
- Birth
- 4 days
- Between birth and 8 weeks
- By 2-3 months
Question 5 of 6
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Which reflex is the nurse assessing by touching an infant’s feet?
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- MoroThe Moro reflex is assessed by supporting the infant in a semi-sitting position and allowing the head and trunk to drop back to a 30-degree angle, not by touching the infant’s feet.
- Correct
- PlantarThe plantar reflex should be assessed by touching the plantar surface of the infant’s feet at the base of the toes.
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- RootingThe rooting reflex is assessed by touching the corner of the infant’s mouth, not by touching the infant’s feet.
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- Palmar graspThe palmar grasp reflex is assessed by touching the palm of the infant’s hand from the ulnar side, not by touching the plantar surface of the infant’s feet.
Question 6 of 6
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Which reflex is the nurse assessing by turning an infant’s head to one side?
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- MoroThe Moro reflex is assessed by supporting the infant in a semi-sitting position and allowing the head and trunk to drop back to a 30-degree angle, not by turning the infant’s head to one side.
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- PlantarThe plantar reflex is assessed by touching the plantar surface of the infant’s feet at the base of the toes, not by turning the infant’s head to one side.
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- RootingThe rooting reflex is assessed by touching the corner of the infant’s mouth, not by turning the infant’s head to one side.
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- SteppingThe stepping reflex is assessed by holding the infant upright and allowing the soles of the feet to touch the table, not by turning the infant’s head to one side.
- Correct
- Asymmetric tonic neckThe asymmetric tonic neck reflex is assessed by laying the infant supine and turning the head to one side to observe extension of the arm and leg on the side to which the head is turned and flexion of the opposite arm and leg.