this reflex present at birth is elicited by stroking the sole of the infants foot resulting in the fanning of the toes
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Nursing Elites

ATI RN

Nursing Care of Children Final ATI

1. 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.

2. What is the priority nursing intervention for a child with epiglottitis?

Correct answer: B

Rationale: The correct answer is B: Maintain airway patency. When dealing with a child with epiglottitis, the priority nursing intervention is to ensure airway patency to prevent airway obstruction, which can lead to respiratory distress or failure. Administering antibiotics (choice A) is important to treat the infection, but airway management takes precedence. Providing hydration (choice C) and monitoring vital signs (choice D) are essential aspects of care but are secondary to securing the airway in a child with epiglottitis.

3. When auscultating an infant's lungs, the nurse detects diminished breath sounds. What should the nurse interpret this as?

Correct answer: C

Rationale: Diminished breath sounds in an infant are an abnormal finding and warrant further investigation to rule out conditions like atelectasis or pneumonia.

4. When assessing a preschooler's chest, what should the nurse expect?

Correct answer: D

Rationale: In a preschooler, chest movement should be symmetric and coordinated with breathing, indicating healthy respiratory function.

5. Which type of breath sound is normally heard over the entire surface of the lungs except for the upper intrascapular area and the area beneath the manubrium?

Correct answer: A

Rationale: Vesicular breath sounds are normally heard over most of the lung fields, except near the trachea and main bronchi, where bronchial or bronchovesicular sounds may be heard.

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