A nurse is caring for an 18-month-old toddler who has been hospitalized for 10 days. After the toddler's mother leaves the room, the nurse observes the toddler sitting quietly in the cornerof the crib, sucking her thumb. When the nurse approaches the crib, the toddler turns away from the nurse. The nurse should understand that these behaviors indicate which of the following developmental reactions?

An anxiety reaction

Regression

Resentment toward the mother

Developing autonomy

Answer and Explanation

The Correct Answer is A

A. An anxiety reaction: The toddler's behavior of sitting quietly, sucking her thumb, and turning away from the nurse when approached after her mother leaves the room suggests anxiety. These

behaviors are common signs of distress or discomfort in young children, especially when separated from their primary attachment figure (in this case, the mother).

B. Regression: Regression involves reverting to earlier, more immature behaviors in response to stress or discomfort. While thumb sucking can be considered a form of regression, the behavior observed in this scenario is more indicative of anxiety rather than a broader regression in

developmental milestones.

C. Resentment toward the mother: There is no evidence in the scenario to suggest that the toddler is expressing resentment toward the mother. The behaviors observed are more likely related to

the child's emotional response to separation and hospitalization.

D. Developing autonomy: Developing autonomy typically involves asserting independence and exploring one's environment. The behaviors observed in the scenario are more indicative of anxiety and distress rather than autonomous behavior.

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Correct Answer is D

Explanation

A. TympaniC. Tympanic temperature measurement using an ear thermometer is a convenient and accurate method for assessing temperature in children, including toddlers.

B. Oral: Oral temperature measurement using a digital thermometer placed under the tongue is a commonly used method for children who can cooperate with the procedure and keep the

thermometer in their mouth.

C. Axillary: Axillary temperature measurement using a thermometer placed in the armpit is a non-invasive method suitable for children who cannot cooperate with oral or tympanic

measurements or when rectal measurement is contraindicated.

D. Rectal: Rectal temperature measurement is generally considered the most accurate method for assessing temperature in infants and young children, especially when accuracy is critical.

However, it may be less appropriate in the emergency department setting due to its invasive nature and potential discomfort for the child, especially in cases of diarrhea or vomiting where rectal temperature measurement may be difficult or impractical.

A. "This is a primitive reflex known as the palmar grasp." B. "This is a protective reflex known as rooting." C. "This is a primitive reflex known as the plantar grasp." D. "This is a protective reflex known as the Moro reflex."

Correct Answer is A

Explanation

A. "This is a primitive reflex known as the palmar grasp.": The palmar grasp reflex is a primitive reflex observed in newborns where they automatically grasp onto objects (or fingers) that touch

their palms. This reflex typically disappears by around 6 months of age.

B. "This is a protective reflex known as rooting.": Rooting is a reflex where newborns turn their head and open their mouth in response to cheek or mouth stimulation, facilitating breastfeeding. It is not related to grasping objects with the hands.

C. "This is a primitive reflex known as the plantar grasp.": The plantar grasp reflex is similar to the palmar grasp but occurs when pressure is applied to the sole of the foot. It is unrelated to grasping objects with the hands.

D. "This is a protective reflex known as the Moro reflex.": The Moro reflex, also known as the startle reflex, involves the newborn's arms and legs extending and then flexing in response to a sudden movement or loud noise. It is not related to grasping objects with the hands.

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Naxlex Comprehensive Predictor Exams

A mother brings her 3-year-old daughter to the emergency department because the child has been vomiting and having diarrhea for the past 36 hours. When assessing this child'stemperature, which method would be least appropriate?

Correct Answer is D

Explanation

A new mother shows the nurse that her baby grasps her finger when she touches the baby's palm. How might the nurse respond to this information?

Correct Answer is A

Explanation

A nurse is collecting data from a child who is descending stairs by placing both feet on each step and holding on to the railing. The nurse should understand that these actions aredevelopmentally appropriate at which of the following ages?

A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

The nurse has seen a 15-year-old girl and a 16-year-old boy during health surveillance visits. Which physical characteristics would be seen in both teenagers?

A nurse in a clinic is assessing a 7-month-old infant. Which of the following indicates a need for further evaluation?

When describing the various changes that occur in organ systems during adolescence, what would the nurse include?

The nurse is conducting a physical examination of a child following a comprehensive health history. What should be the focus of the physical examination?

A nurse is assessing the psychosocial development of a toddler. The nurse should recognize that this stage is characterized by which of the following?

A nurse is caring for a child who is on a clear liquid diet. At lunch, the child consumed 1⁄2 cup of juice, 3 oz gelatin, 1 oz of an ice pop, and 20 mL ginger ale. How many mL should the nurse record as the child's fluid intake?