The nurse is caring for an 8-month-old baby diagnosed with spastic cerebral palsy. Which assessment finding supports this medical diagnosis?
A) The child has a strong Moro reflex when startled.
B) The child bears weight on both feet when held upright.
C) The child cries when held in a ventral suspension position.
D) The child holds the back very straight when in a sitting position.
A
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Spasticity is excessive tone in the voluntary muscles that results in loss of upper motor neurons. A child with spastic cerebral palsy has hypertonic muscles, abnormal clonus, exaggeration of deep tendon reflexes, abnormal reflexes such as a positive Babinski reflex, and continuation of neonatal reflexes, such as the tonic neck reflex, well past the age at which these usually disappear. If infants with this disorder are held in a ventral suspension position, they arch their backs and extend their arms and legs abnormally. They tend to assume a "scissors gait" because tight adductor thigh muscles cause their legs to cross when held upright. This involvement may be so severe it leads to a subluxated hip. Posture when in a sitting position is not remarkable for this health problem.
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