which reflex is expected to disappear by 4 months of age
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Nursing Elites

ATI RN

ATI Nursing Care of Children 2019 B

1. Which reflex is expected to disappear by 4 months of age?

Correct answer: B

Rationale: The Moro reflex, also known as the startle reflex, typically disappears by 4 months as the infant's nervous system matures. This reflex is important for assessing the development of the nervous system in newborns. The Rooting reflex (Choice A) is related to turning the head in response to cheek stimulation; the Babinski reflex (Choice C) involves the fanning of toes in response to foot stimulation; and the Palmar grasp (Choice D) is the curling of the fingers around an object placed in the infant's hand. These reflexes have different timelines for disappearance and are not typically expected to be gone by 4 months of age.

2. The clinic nurse is instructing parents about caring for a toddler with ascariasis (common roundworm). Which statement made by the parents indicates a need for further teaching?

Correct answer: B

Rationale: Roundworm (ascariasis) is typically transmitted through ingestion of contaminated soil, not directly from person to person. This statement indicates a misunderstanding requiring clarification.

3. What type of dehydration occurs when the electrolyte deficit exceeds the water deficit?

Correct answer: B

Rationale: Hypotonic dehydration occurs when the loss of electrolytes exceeds the loss of water, leading to a decrease in plasma osmolarity. This often occurs when sodium loss is greater than water loss, as in diarrhea or vomiting.

4. Pertussis vaccination should begin at which age?

Correct answer: B

Rationale: The DTaP vaccine, which includes pertussis, is typically started at 2 months of age as part of the recommended immunization schedule.

5. As the primary caregiver for a 5-month-old baby, according to Maslow’s hierarchy of basic needs, which intervention takes the highest priority?

Correct answer: A

Rationale: The correct answer is A: Feeding every four hours. According to Maslow’s hierarchy of needs, physiological needs, such as food, water, and warmth, take the highest priority. Ensuring that the baby is fed regularly is crucial for survival and overall health. Choice B, protection from harm, relates more to safety needs which come after physiological needs. Choice C, providing stimulation, is associated with higher-level needs like belongingness and esteem. Choice D, providing love, corresponds to esteem and self-actualization needs, which are higher in the hierarchy than physiological needs.

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