A nurse is collecting data from a 9-month-old infant. Which of the following findings would require further
intervention?
Rationale: The Babinski reflex
... [Show More] disappears after 1 year of age. Therefore, a 9-month-old infant
with a positive Babinski reflex is a finding that does not require further intervention.
A. Positive Babinski reflex
Rationale: The Moro reflex disappears approximately at 3-4 months of age. Therefore, a 9-
month-old infant with a positive Moro reflex is a finding that requires further
intervention
B. Positive Moro reflex
Rationale: A negative Doll’s eye reflex is a normal finding. Therefore, a 9-month-old infant with
a negative Doll’s eye reflex is a finding that does not require further intervention.
C. Negative Doll’s eye reflex
Rationale: A negative Crawl reflex disappears after 6 months of age. Therefore, a 9-month-old
infant with a negative Crawl reflex is a finding that does not require further
intervention.
D. Negative Crawl reflex
1.
A nurse is reinforcing teaching a parent of a child who has a fracture of the epiphyseal plate. Which of the
following is an appropriate statement by the nurse?
Rationale: Children heal fractures in less time than adults because of the generous blood
supply to the bone and the epiphyseal plate.
A. “The blood supply to the bone is disrupted.”
Rationale: A fracture of the epiphyseal plate can affect growth in a child. Therefore, it needs to
be detected and treated rapidly.
B. “Normal bone growth can be affected.”
Rationale: The epiphyseal plate is the cartilage growth plate. Therefore, bone marrow is not
lost through this type of fracture.
C. “Bone marrow can be lost though the fracture.”
Rationale: Children heal fractures in less time than adults because of the generous blood
supply to the bone and the epiphyseal plate.
D. “The healing process will take longer.”
2.
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Detailed Answer Key
Homework 8 - Pediatrics
A nurse is planning to speak to a group of adolescents about toxic shock syndrome (TSS). The nurse knows
that TSS is commonly associated with which of the following?
Rationale: Toxic shock syndrome, a severe disease caused by a toxin made by
Staphylococcus aureus, is characterized by shock and multiple organ dysfunction. It
most often affects menstruating women who use highly absorbent tampons.
A. High-absorbency tampons
Rationale: Mosquito bites are not associated with TSS.
B. Mosquito bites
Rationale: International travel is not associated with TSS.
C. International travel
Rationale: TSS is not associated with multiple sexual partners.
D. Multiple sexual partners
3.
A nurse is collecting data from an infant. Which of the following is a clinical manifestation of pyloric stenosis?
Rationale: Visible gastric peristaltic waves moving from the left to the right are a clinical
manifestation of pyloric stenosis.
A. Absent bowel sounds
Rationale: Vomiting causes a depletion of fluid and electrolytes, therefore a decrease in serum
sodium levels is a clinical manifestation of pyloric stenosis.
B. Increased sodium level
Rationale: Pyloric stenosis is a narrowing and thickening of the pyloric canal between the
stomach and the duodenum resulting in projectile vomiting.
C. Projectile vomiting after feedings
Rationale: An olive-shaped mass is palpable right of the umbilicus is a clinical manifestation of
pyloric stenosis.
D. Golf ball-sized mass over the left quadrant
4.
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Detailed Answer Key
Homework 8 - Pediatrics
A nurse is planning care for a child who has juvenile rheumatoid arthritis. Which of the following is an
appropriate action for the nurse to take?
Rationale: NSAIDs are used to control pain. Therefore, administering opioids on a schedule is
not an appropriate action for the nurse to take.
A. Administer opioids on a schedule.
Rationale: Physical mobility will assist in preserving function and maintaining mobility.
Therefore, prolonged periods of complete joint immobilization is not an appropriate
action for the nurse to take.
B. Schedule prolonged periods of complete joint immobilization daily.
Rationale: Heat is beneficial for relieving pain and stiffness. Therefore, applying cool
compresses for 20 minutes every hour is not an appropriate action for the nurse to
take.
C. Apply cool compresses for 20 minutes every hour.
Rationale: Maintaining night splints to the affected joints will assist in range of motion.
Therefore, this is an appropriate action for the nurse to take.
D. Maintain night splints to the affected joint.
5.
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Detailed Answer Key
Homework 8 - Pediatrics
A nurse is caring for a school-age child who has mild persistent asthma. Which of the following is an expected
finding? (Select all that apply.)
A. Symptoms are continuous throughout the day.
B. Daytime symptoms occur more than twice a week.
C. Nighttime symptoms occur approximately twice a month.
D. Minor limitations occur with normal activity.
E. Peak expiratory flow (PEF) is greater than or eq [Show Less]