Which reflexes will the nurse assess to determine brainstem response in a patient being evaluated for brain death? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply
1. PERLA
2. Oculovestibular
3. Corneal
4. Oculocephalic
5. Moro
1,2,3,4
Rationale 1: Absence of brainstem reflexes is determined by pupils 4 mm or larger that do not respond to light.
Rationale 2: Brainstem response can be determined by assessing the oculovestibular reflex.
Rationale 3: Brainstem response can be determined by assessing the corneal reflex.
Rationale 4: Brainstem response can be determined by assessing the oculocephalic reflex.
Rationale 5: Moro reflex is seen soon after birth and disappears with the development of the infant. It is also called the startle reflex that creates a flexion of the thighs and knees and a fanning out of the arms, as if trying to embrace someone.
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