1. A nurse is collecting data from a 9-month-old infant. Which of the following findings would require further
intervention?
A. Positive Babinski reflex
Rationale: The Babinski reflex disappears after 1 year of age. Therefore, a 9-monthold infant with a
positive Babinski reflex is a finding that does not require further intervention.
B. Positive Moro 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
C. Negative Doll’s eye 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.
D. Negative Crawl reflex
Rationale: A negative Crawl reflex disappears after 6 months of age. Therefore, a 9month-old infant
with a negative Crawl reflex is a finding that does not require further intervention.
, Detailed Answer Key
Homework 8 - Pediatrics
2. 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?
A. “The blood supply to the bone is disrupted.”
Rationale: Children heal fractures in less time than adults because of the generous blood supply to the
bone and the epiphyseal plate.
B. “Normal bone growth can be affected.”
Rationale: A fracture of the epiphyseal plate can affect growth in a child. Therefore, it needs to be
detected and treated rapidly.
C. “Bone marrow can be lost though the fracture.”
Rationale: The epiphyseal plate is the cartilage growth plate. Therefore, bone marrow is not lost
through this type of fracture.
D. “The healing process will take longer.”
Rationale: Children heal fractures in less time than adults because of the generous
CAA_DetailedAnswerKey10/05/2012 created page 1 of
blood supply to the bone and the epiphyseal plate.
, Detailed Answer Key
Homework 8 - Pediatrics
2
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, Detailed Answer Key
Homework 8 - Pediatrics
3. 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?
A. High-absorbency tampons
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.
B. Mosquito bites
Rationale: Mosquito bites are not associated with TSS.
C. International travel
Rationale: International travel is not associated with TSS.
D. Multiple sexual partners
Rationale: TSS is not associated with multiple sexual partners.
4. A nurse is collecting data from an infant. Which of the following is a clinical manifestation of pyloric stenosis?
A. Absent bowel sounds
Rationale: Visible gastric peristaltic waves moving from the left to the right are a clinical
manifestation of pyloric stenosis.
B. Increased sodium level
Rationale: Vomiting causes a depletion of fluid and electrolytes, therefore a decrease in serum
sodium levels is a clinical manifestation of pyloric
stenosis.
C. Projectile vomiting after feedings
Rationale: Pyloric stenosis is a narrowing and thickening of the pyloric canal between the stomach
and the duodenum resulting in projectile vomiting.
D. Golf ball-sized mass over the left quadrant
Rationale: An olive-shaped mass is palpable right of the umbilicus is a clinical manifestation of pyloric
stenosis.
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