Which reflex, present at birth, is elicited by stroking the sole of the infant's foot, resulting in the fanning of the toes?

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Nursing Care of Children Final ATI Questions

Question 1 of 5

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.

Question 2 of 5

The nurse is assessing a child with type 2 diabetes. The child is awake and alert with a serum glucose of 60 mg/dL. What action should the nurse take?

Correct Answer: C

Rationale: For a conscious child with mild hypoglycemia, giving 15 grams of fast-acting carbohydrates is the appropriate intervention. This can quickly raise blood glucose levels to prevent further complications. Administering insulin (Choice A) would further lower the glucose level, which is not suitable in this scenario. Administering epinephrine (Choice B) is not indicated for hypoglycemia. Glucagon (Choice D) is used for severe hypoglycemia with altered consciousness, not for mild cases where the child is awake and alert.

Question 3 of 5

A child is admitted to the hospital with acute renal failure. The parents ask about the prognosis for acute renal failure. The nurse's response should be based on which statement about acute renal failure?

Correct Answer: C

Rationale: The correct answer is C: Acute renal failure in children is often reversible, especially when the underlying cause is identified and treated promptly. It does not always lead to chronic renal failure or the need for a kidney transplant. Choice A is incorrect as prophylactic antibiotics for life are not a standard treatment for acute renal failure. Choice B is incorrect as acute renal failure does not always progress to chronic renal failure. Choice D is incorrect as not all children with acute renal failure will eventually require a kidney transplant.

Question 4 of 5

The nurse is caring for a child with acute postinfectious glomerulonephritis. Which of the following best describes the pathophysiology of acute postinfectious glomerulonephritis?

Correct Answer: B

Rationale: The correct answer is B: 'Occurs after a streptococcal infection.' Acute postinfectious glomerulonephritis often occurs after an infection with certain strains of streptococcus bacteria, specifically group A streptococcus. The body's immune response to the infection leads to inflammation and damage in the kidneys. Choices A, C, and D are incorrect because acute postinfectious glomerulonephritis is primarily associated with streptococcal infections, not urinary tract infections, renal vascular disorders, or E. coli.

Question 5 of 5

The nurse is providing education to the parent of a child with Beta-thalassemia. Which risk factors about the condition should the nurse include in the teaching?

Correct Answer: D

Rationale: The correct answer is D: Chronic hypoxia and iron overload. Children with Beta-thalassemia often suffer from chronic hypoxia due to ineffective erythropoiesis and require frequent blood transfusions, leading to iron overload. These complications must be managed to prevent organ damage. Choices A, B, and C are incorrect. Hypertrophy of the thyroid, polycythemia vera, and thrombocytopenia are not direct risk factors associated with Beta-thalassemia. Therefore, they should not be included in the teaching regarding this condition.

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