ATI MED SURG (PAEDS )EXAM 2020

A nurse in the pediatrician's office is checking the Babinski reflex in a 3-month-old infant. The nurse determines that the infant's response is normal if which of the following findings is noted? 
 A The infant turns to the side that is touched. B The fingers curl tightly and the toes curl forward. C The toes flare and the big toe is dorsiflexed. Correct D There is extension of the extremities on the side to which the head is turned, with flexion on the opposite side. 


Rationale: To elicit the Babinski reflex, the nurse strokes the lateral sole of the foot from the heel to across the base of the toes. In the expected response, the toes flare and the big toe dorsiflexes. The Babinski reflex disappears at 12 months of age. Turning to the side that is touched is the expected response when the rooting reflex is elicited. Tight curling of the fingers and forward curling of the toes is the expected response when the grasp reflex (palmar and plantar) is elicited. Extension of the extremities on the side to which the head is turned with flexion on the opposite side is the expected response when the tonic neck reflex is elicited. Test-Taking Strategy: Knowledge regarding the method of testing and the expected response of the Babinski reflex is needed to answer this question. Recalling that to elicit Babinski reflex the nurse would stroke the lateral sole of the foot will direct you to the correct option. Review the procedure for testing this reflex in an infant and the expected response if you had difficulty with this question. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed., p. 516). St. Louis: Elsevier. Level of Cognitive Ability: Analyzing Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Newborn Awarded 1.0 points out of 1.0 possible points. 





 2.
ID: 
A nurse is assessing language development in a toddler from a bilingual family. The nurse expects that the child’s language development: 
 A Is slower than expected Correct B Is developing as expected C Is more advanced than expected D Will require assistance from a speech therapist 


Rationale: Although the age at which children begin to talk varies widely, most can communicate verbally by the second birthday. The rate of language development depends on physical maturity and the amount of reinforcement the child has received. Children of bilingual families, twins, and children other than firstborns may have slower language development. A child from a bilingual family does not require assistance from a speech therapist to ensure language development. Test-Taking Strategy: Use the process of elimination. Note that there are no data in the question to indicate that the child needs assistance from a speech therapist. When selecting from the remaining options, noting the word "bilingual" in the question and recalling the factors that affect language development will direct you to the correct option. Review the factors that affect language development if you had difficulty with this question. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed., p. 111). St. Louis: Elsevier. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Cultural Diversity Awarded 1.0 points out of 1.0 possible points. 





 3.
ID: 
A nurse notes the presence of variable decelerations on the fetal heart rate monitor strip and suspects cord compression. The nurse should immediately: 
 A Notify the nurse-midwife or physician B Perform a vaginal examination on the mother C Position the mother so that her hips are elevated Correct D Insert a gloved finger into the mother's vagina to feel for cord compression 


Rationale: Conditions that restrict blood flow through the umbilical cord may result in variable decelerations. If cord compression is suspected, the mother is immediately repositioned. She may be turned to her side, or her hips may be elevated to shift the fetal presenting part toward her diaphragm. A hands-and-knees position may also reduce compression of a cord that is trapped behind the fetus. Several position changes may be required before the pattern improves or resolves. The nurse may need to contact the nurse-midwife or physician, but this would not be the immediate action. Although the nurse may check the woman’s vaginal area for the presence of the umbilical cord, a vaginal exam is not performed because of the possibility of further compromise of blood flow through the umbilical cord. Because of this risk, the nurse would not insert a gloved finger into the vagina to feel for the cord. Test-Taking Strategy: Note the strategic word "immediately" in the query of the question and use the ABCs — airway, breathing, and circulation — to answer the question. The only action that would provide circulation is positioning the mother so that her hips are elevated, which would relieve cord compression. Review the immediate nursing measures when cord compression is suspected if you had difficulty with this question. References: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed., p. 400). St. Louis: Elsevier. Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal-child nursing care (4th ed., p. 432). St. Louis: Elsevier.