A nurse in the pediatrician-EXAM 1

□ 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: 283572974A 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: 283573460A 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.
□
□ Level of Cognitive Ability: Applying
□
□ Client Needs: Health Promotion and Maintenance
□
□ Integrated Process: Nursing Process/Implementation
□
□ Content Area: Critical Care Awarded 1.0 points out of
1.0 possible points.
□ 4.ID: 283573402A nurse is assessing the language
development of a 9-month-old infant. Which developmental
milestone does the nurse expect to note in an infant of this
age?
A The infant babbles.
B The infant says "Mama." Correct
C The infant smiles and coos.
D The infant babbles single consonants.
□ Rationale: An 8- to 9-month-old infant can string vowels
and consonants together. The first words, such as "Mama,"
"Daddy," "bye-bye," and "baby," begin to have meaning. A
1- to 3-month-old infant produces cooing sounds. Babbling
is common in a 3- to 4-month-old. Single-consonant
babbling occurs between 6 and 8 months of age.
□
□ Test-Taking Strategy: Use the process of elimination and
focus on the age of the infant. Recalling the language
development that occurs during infancy will direct you to the
correct option. Remember that an 8- to 9-month-old infant
can string vowels and consonants together. Review the
developmental milestones related to language development
in an infant if you had difficulty with this question.
□
□ Reference: McKinney, E., James, S., Murray, S., &
Ashwill, J. (2009). Maternal-child nursing (3rd ed., pp. 80,
99). St. Louis: Elsevier.