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 appropriate placement of a tongue blade for assessment of the mouth and throat?

Correct answer: B

Rationale: The side of the tongue is the appropriate place for a tongue blade to avoid triggering the gag reflex during assessment of the mouth and throat.

3. At which age should the nurse expect most infants to begin to say mama and dada with meaning?

Correct answer: C

Rationale: By around 10 months, infants often start to say "mama" and "dada" with meaning, associating these words with their parents.

4. The nurse is caring for an adolescent hospitalized for asthma. The adolescent belongs to a large family. The nurse recognizes that the adolescent is likely to relate to which group?

Correct answer: A

Rationale: Adolescents typically identify and relate more closely to their peer group, especially during the teenage years when peer relationships become a central focus.

5. The nurse is preparing to admit a 10-year-old child with appendicitis. What clinical manifestations should the nurse expect to observe?

Correct answer: D

Rationale: Correct! Typical signs of appendicitis include fever, vomiting, and tachycardia due to infection and inflammation. These clinical manifestations are commonly observed in patients with appendicitis. Hyperactive bowel sounds are not typically associated with appendicitis, so they are not expected findings in this situation. Therefore, the correct answer is 'All of the above.'

Similar Questions

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A 3-year-old child, previously potty-trained, becomes a bed-wetter again during a hospital stay. Which explanation should the nurse provide to the parents?
The mother of a child with cognitive impairment calls the nurse because her son has been gagging and drooling all morning. The nurse suspects foreign body ingestion. What physiologic occurrence is most likely responsible for the presenting signs?
The nurse is preparing an airborne infection isolation room for a patient. Which communicable disease does the patient likely have?
What clinical manifestation should be the most suggestive of acute appendicitis?

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