the parents of a 2 year old boy who had a repair of exstrophy of the bladder at birth ask when they can begin toilet training their son the nurse repl
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Nursing Elites

ATI RN

RN Nursing Care of Children 2019 With NGN

1. The parents of a 2-year-old boy who had a repair of exstrophy of the bladder at birth ask when they can begin toilet training their son. The nurse replies based on what knowledge?

Correct answer: B

Rationale: Toilet training should begin when the child has sufficient bladder capacity and control, which may be delayed in children who have undergone surgical repairs for conditions like bladder exstrophy. Premature training can lead to frustration and setbacks.

2. The nurse is assessing a child's capillary refill time. This can be accomplished by doing what?

Correct answer: D

Rationale: Capillary refill time is assessed by applying pressure to the nail bed and observing how quickly the color returns, indicating peripheral circulation status.

3. According to Erikson’s developmental theory, toddlers need to be encouraged to become independent to successfully complete which developmental challenge?

Correct answer: C

Rationale: The correct answer is C: Autonomy vs. shame and doubt. Erikson's developmental stage for toddlers focuses on the conflict between developing a sense of independence (autonomy) and feelings of inadequacy (shame and doubt). Encouraging toddlers to explore their environment and make choices helps them build self-confidence and independence. Choices A, B, and D are incorrect because trust vs. mistrust relates to infancy, industry vs. inferiority is associated with school-age children, and initiative vs. guilt is linked to preschoolers.

4. The school nurse is evaluating the number of school-age children classified as obese. The nurse recognizes that the percentile of body mass index that classifies a child as obese is greater than which?

Correct answer: D

Rationale: A child with a BMI greater than the 95th percentile is classified as obese, according to standard growth charts used in pediatric practice.

5. Which reflex, present at birth, is elicited by stroking the sole of the infant's foot, resulting in the fanning of the toes?

Correct answer: A

Rationale: The Babinski reflex is the correct answer. This reflex is characterized by the fanning out of the toes when the sole of the foot is stroked. It is a normal reflex in infants and is typically present at birth, disappearing by around 12 months of age. The Moro reflex, which involves the infant's response to a sudden loss of support or a loud noise, is not related to the fanning of toes. Sucking and rooting reflexes are related to feeding behaviors and are not elicited by stroking the sole of the foot.

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