INFANT
1. Which statement accurately describes an event associated with an infant's physical
development?
a. Anterior fontanel closes by age 6 to 10 months.
b. Binocularity is well established by age 8 months.
c. Birth weight doubles by age 5 months and triples by age 1 year.
d. Maternal iron stores persist during the first 12 months of life.
ANS: C
Growth is very rapid during the first year of life. The birth weight approximately doubles
by age 5 to 6 months and triples by age 1 year. The anterior fontanel closes at age 12 to
18 months. Binocularity is not established until age 15 months. Maternal iron stores are
usually depleted by age 6 months.
2. The nurse assessing a 6-month-old healthy infant who weighed 7 lbs at birth, shares
with the parents that the infant should weigh approximately how many pounds?
a. 10 lbs.
b. 15 lbs.
c. 20 lbs.
d. 25 lbs.
ANS: B
Birth weight doubles at about age 5 to 6 months. At 6 months, an infant who weighed 7
lbs at birth would weigh approximately 15 lbs. Ten pounds is too little; the infant would
have gone from the 50th percentile at birth to below the 5th percentile. Twenty pounds
or more is too much; the infant would have tripled the birth weight at 6 months.
3. The nurse is doing a routine assessment on a 14-month-old infant and notes that the
anterior fontanel is closed. This should be interpreted as:
a. a normal finding.
b. a questionable finding—the infant should be rechecked in 1 month.
c. an abnormal finding—indicates the need for immediate referral to a practitioner.
d. an abnormal finding—indicates the need for developmental assessment.
ANS: A
Because the anterior fontanel normally closes between ages 12 and 18 months, this is a
normal finding, and no further intervention is required.
4. By what age does the posterior fontanel usually close?
a. 6 to 8 weeks
b. 10 to 12 weeks
c. 4 to 6 months
d. 8 to 10 months
ANS: A
The bones surrounding the posterior fontanel fuse and close by age 6 to 8 weeks. Ten
weeks or longer is too late and indicates a problem.
5. The parents of a 9-month-old infant tell the nurse that they have noticed foods such
as peas and corn are not completely digested and can be seen in their infant's stool.
The nurse bases her explanation on what fact?
a. Children should not be given fibrous foods until the digestive tract matures at age 4
years.
b. The infant should not be given any solid foods until this digestive problem is resolved.
c. This is abnormal and requires further investigation.
d. This is normal because of the immaturity of digestive processes at this age.
ANS: D
The immaturity of the digestive tract is evident in the appearance of the stools. Solid
foods are passed incompletely broken down in the feces but it is not necessity to
eliminate solid foods. An excess quantity of fiber predisposes the child to large, bulky
stools. This is a normal part of the maturational process, and no further investigation is
necessary.
6. A 3-month-old infant, born at 38 weeks of gestation, will hold a rattle if it is put in her
hands; however, she will not voluntarily grasp it. How should the nurse interpret this
behavior?
a. Normal development
b. Significant developmental lag
c. Slightly delayed development caused by prematurity
d. Suggestive of a neurologic disorder such as cerebral palsy
ANS: A
This indicates normal development. Reflexive grasping occurs during the first 2 to 3
months and then gradually becomes voluntary. No evidence of developmental lag,
delayed development, or neurologic dysfunction is present by this behavior.
7. The nurse determines an infant of 7 months is demonstrating appropriate fine motor
development when performing which action?
a. Transferring a rattler from one hand to the other.
b. Using thumb and index finger to grasp a piece of food.
c. Holding a crayon and make a mark on paper.
d. Releasing cubes into a cup.
ANS: A
By age 7 months, infants can transfer objects from one hand to the other, crossing the
midline. The crude pincer grasp is apparent at about age 9 months. The infant can
scribble spontaneously at age 15 months. At age 12 months, the infant can release
cubes into a cup.
8. In terms of gross motor development, what hallmark action should the nurse identify
for the parents of a 5-month-old infant to anticipate?
a. Roll from abdomen to back.
b. Roll from back to abdomen.
c. Sit erect without support.
d. Move from prone to sitting position.
ANS: A
Rolling from abdomen to back is developmentally appropriate for a 5-month-old infant.
The ability to roll from back to abdomen usually occurs at 6 months old. Sitting erect
without support is a developmental milestone usually achieved by 8 months. The
10-month-old infant can usually move from a prone to a sitting position.
9. At which age can most infants sit steadily unsupported?
a. 4 months
b. 6 months
c. 8 months
d. 10 months
ANS: C
Sitting erect without support is a developmental milestone usually achieved by 8
months. At age 4 months, an infant can sit with support. At age 6 months, the infant will
maintain a sitting position if propped. By 10 months, the infant can maneuver from a
prone to a sitting position.
10. By what age should the nurse expect that an infant will be able to pull to a standing
position?
a. 6 months
b. 8 months
c. 9 months
d. 11 to 12 months
ANS: C
Most infants can pull themselves to a standing position at age 9 months. Any infant who
cannot pull to a standing position by age 11 to 12 months should be referred for further
evaluation for developmental dysplasia of the hips (DDH). At 6 months, the infant has
just obtained coordination of arms and legs. By age 8 months, infants can bear full
weight on their legs.
11. According to Piaget, the 6-month-old infant would be in what stage of the
sensorimotor phase?
a. Use of reflexes
b. Primary circular reactions
c. Secondary circular reactions
d. Coordination of secondary schemata
ANS: C
Infants are usually in the secondary circular reaction stage from age 4 months to 8
months. This stage is characterized by a continuation of the primary circular reaction for
the response that results. For example, shaking of a rattle is performed to hear the
noise of the rattle, not just for shaking. The use of reflexes is primarily during the first
month of life. The primary circular reaction stage marks the replacement of reflexes with
voluntary acts. The infant is in this stage from age 1 month to 4 months. The fourth
sensorimotor stage is coordination of secondary schemata. This is a transitional stage
in which increasing motor skills enable greater exploration of the environment.
12. Which behavior indicates that an infant has developed object permanence?
a. Recognizes familiar face such as the mother
b. Recognizes familiar object such as a bottle
c. Actively searches for a hidden object
d. Secures objects by pulling on a string
ANS: C
During the first 6 months of life, infants believe that objects exist only as long as they
can see them. When infants search for an object that is out of sight, this signals the
attainment of object permanence, whereby an infant knows that an object exists even
when it is not visible. Between ages 8 and 12 weeks, infants begin to respond
differentially to their mothers. They cry, smile, vocalize, and show distinct preference for
their mothers. This preference is one of the stages that influence the attachment
process, but it is too early for object permanence. Recognizing familiar objects is an
important transition for the infant, but it does not signal object permanence. The ability
to understand cause and effect, such as pulling on a string to secure an object, is part of
secondary schema development.
13. A parent asks the nurse "At what age do most babies begin to fear strangers?" The
nurse responds that most infants begin to fear strangers at what age?
a. 2 months
b. 4 months
c. 6 months
d. 12 months
ANS: C
Between ages 6 and 8 months, fear of strangers and stranger anxiety become
prominent and are related to the infant's ability to discriminate between familiar and
nonfamiliar people. At age 2 months, the infant is just beginning to respond differentially
to the mother. At age 4 months, the infant is beginning the process of separation
individuation when the infant begins to recognize self and mother as separate beings.
Twelve months is too late and requires referral for evaluation if the infant does not fear
strangers at this age.
14. The nurse is interviewing the father of 10-month-old. When the child, playing on the
floor and notices an electrical outlet and reaches up to touch it, the father says "No"
firmly and removes the child away from the outlet. The nurse should use this opportunity
to teach the father that the child is capable of understanding what association?
a. Understand the word "No."
b. Father always means "No."
c. Electrical outlets are dangerous.
d. Spanking as a deterrent.
ANS: A
By age 10 months, children are able to associate meaning with words. The child should
be old enough to understand the word "No." The 10-month-old is too young to
understand the purpose of an electrical outlet and is not likely to always associate her
father with the word "No." The father is using both verbal and physical cues to teach
safety measures and alert the child to dangerous situations. Physical discipline should
be avoided.
15. Sara, age 4 months, was born at 35 weeks' gestation. She seems to be developing
normally, but her parents are concerned because she is a "more difficult" baby than their
other child, who was term. The nurse should explain that:
a. infants' temperaments are part of their unique characteristics.
b. infants become less difficult if they are not kept on scheduled feedings and structured
routines.
c. Sara's behavior is suggestive of failure to bond completely with her parents.
d. Sara's difficult temperament is the result of painful experiences in the neonatal
period.
ANS: A
Infant temperament has a strong biologic component. Together with interactions with the
environment, primarily the family, the biologic component contributes to the infant's
unique temperament. Children perceived as difficult may respond better to scheduled
feedings and structured caregiving routines than to demand feedings and frequent
changes in routines. Sara's temperament has been created by both biologic and
environmental factors. The nurse should provide guidance in parenting techniques that
are best suited to Sara's temperament.
16. Which information could be given to the parents of a 12-month-old child regarding
appropriate play activities for this age?
a. Give large push-pull toys for kinesthetic stimulation.
b. Place cradle gym across crib to facilitate fine motor skills.
c. Provide child with finger paints to enhance fine motor skills.
d. Provide stick horse to develop gross motor coordination.
ANS: A
The 12-month-old child is able to pull to a stand and walk holding on or independently.
Appropriate toys for a child of this age include large push-pull toys for kinesthetic
stimulation. A cradle gym should not be placed across the crib. Finger paints are
appropriate for older children. A 12-month-old child does not have the stability to use a
stick horse.
17. Which is an appropriate play activity for a 7-month-old infant to encourage visual
stimulation?
a. Playing peek-a-boo.
b. Playing pat-a-cake.
c. Imitating animal sounds.
d. Showing how to clap hands.
ANS: A
Because object permanence is a new achievement, peek-a-boo is an excellent activity
to practice this new skill for visual stimulation. Playing pat-a-cake and showing how to
clap hands will help with kinesthetic stimulation. Imitating animal sounds will help with
auditory stimulation.
18. At what age should the nurse expect an infant to begin smiling in response to
pleasurable stimuli?
a. 1 month
b. 2 months
c. 3 months
d. 4 months
ANS: B
At age 2 months, the infant has a social, responsive smile. A reflex smile is usually
present at age 1 month. The 3-month-old can recognize familiar faces. At age 4 months,
the infant can enjoy social interactions.
19. The mother of a breastfed infant being seen in the clinic for the sixth month checkup
is concerned that the infant has begun thumb sucking. How should the nurse respond to
the mother's concern?
a. Recommend that the mother substitute a pacifier for the infant's thumb.
b. Assess the infant for other signs of sensory deprivation.
c. Reassure the mother that this behavior is very normal at this age.
d. Suggest that the mother breastfeed more often to satisfy sucking needs.
ANS: C
Sucking is an infant's chief pleasure, and she may not be satisfied by bottle-feeding or
breastfeeding alone. During infancy and early childhood, there is no need to restrict
nonnutritive sucking. Dental damage does not appear to occur unless the use of the
pacifier or finger persists after age 4 to 6 years. The nurse should explore with the
mother her feelings about pacifier versus thumb. This is a normal behavior to meet
nonnutritive sucking needs. No data support that Latasha has sensory deprivation.
20. How should the nurse describe the fact that a 6 month old has 6 teeth?
a. Normal tooth eruption.
b. Delayed tooth eruption.
c. Unusual and dangerous.
d. Earlier-than-normal tooth eruption.
ANS: D
This is earlier than expected. Most infants at age 6 months have two teeth, the lower
central incisors. Six teeth at 6 months is not delayed; it is early tooth eruption. Although
unusual, it is not dangerous.
1. A mother tells the nurse that she is discontinuing breastfeeding her 5-month-old
infant. What should the nurse recommend to be used as substitute for the breastmilk?
a. Skim milk
b. Whole cow's milk
c. Commercial iron-fortified formula
d. Commercial formula without iron
ANS: C
For children younger than 1 year, the American Academy of Pediatrics recommends the
use of breast milk. If breastfeeding has been discontinued, iron-fortified commercial
formula should be used. Cow's milk should not be used in children younger than 12
months. Maternal iron stores are almost depleted by this age; the iron-fortified formula
will help prevent the development of iron deficiency anemia.
22. When is the best age for solid food to be introduced into the infant's diet?
a. 2 to 3 months
b. 4 to 6 months
c. When birth weight has tripled
d. When tooth eruption has started
ANS: B
Physiologically and developmentally, the 4 to 6 months old is in a transition period. The
extrusion reflex has disappeared, and swallowing is a more coordinated process. In
addition, the gastrointestinal tract has matured sufficiently to handle more complex
nutrients and is less sensitive to potentially allergenic food. Infants of this age will try to
help during feeding. Two to three months is too young. The extrusion reflex is strong,
and the infant will push food out with the tongue. No research base indicates that the
addition of solid food to bottle-feeding has any benefit. Tooth eruption can facilitate
biting and chewing; most infant foods do not require this ability.
23. The parents of a 4-month-old infant tell the nurse that they are getting a microwave
oven and will be able to heat the baby's formula faster. What recommendations should
the nurse provide the parents?
a. Never heat a bottle in a microwave oven.
b. Heat only 10 ounces or more.
c. Always leave the bottle top uncovered to allow heat to escape.
d. Shake the bottle vigorously for at least 30 seconds after heating.
ANS: A
Neither infant formula nor breast milk should be warmed in a microwave oven as this
may cause oral burns as a result of uneven heating in the container. The bottle may
remain cool while hot spots develop in the milk. Warming expressed milk in a
microwave decreases the availability of antiinfective properties and causes separation
of the fat content. Milk should be warmed in a lukewarm water bath. None of the other
options adequately deals with the issue of overheating.
24. The parent of a 2 week old asks the nurse if the infant needs fluoride supplements
because they plan to exclusively breastfed. What is the nurse's best response?
a. "Your infant needs to begin taking them now."
b. "They are not needed if you drink fluoridated water."
c. "Your infant may need to begin taking them at age 6 months."
d. "Your infant can have infant cereal mixed with fluoridated water instead of
supplements."
ANS: C
Fluoride supplementation is recommended by the American Academy of Pediatrics
beginning at age 6 months if the child is not drinking adequate amounts of fluoridated
water. The recommendation is to begin supplementation at 6 months, not at 2 weeks.
The amount of water that is ingested and the amount of fluoride in the water are
evaluated when supplementation is being considered.
25. A mother tells the nurse that she does not want her infant immunized because of the
discomfort associated with injections. The nurse should explain that:
a. this cannot be prevented.
b. infants do not feel pain as adults do.
c. this is not a good reason for refusing immunizations.
d. a topical anesthetic, eutectic mixture of local anesthetic (EMLA), will minimize the
discomfort.
ANS: D
Several topical anesthetic agents can be used to minimize the discomfort associated
with immunization injections. These include EMLA and vapor coolant sprays. Pain
associated with many procedures can be prevented or minimized by using the principles
of atraumatic care. With preparation, the injection site can be properly anesthetized to
decrease the amount of pain felt by the infant. Infants have the neural pathways to
sense pain. Numerous research studies have indicated that infants perceive and react
to pain in the same manner as do children and adults. The mother should be allowed to
discuss her concerns and the alternatives available. This is part of the informed consent
process.
26. The parents of a 12-month-old child ask the nurse if the child can eat hot dogs. The
nurse's reply should be based on what understanding?
a. The child is too young to digest hot dogs.
b. The child is too young to eat hot dogs safely.
c. Hot dogs must be sliced into sections to prevent aspiration.
d. Hot dogs must be cut into small, irregular pieces to prevent aspiration.
ANS: D
Hot dogs are of a consistency, diameter, and round shape that may cause complete
obstruction of the child's airway. If given to young children, the hot dog should be cut
into small irregular pieces rather than served whole or in slices. The child's digestive
system is mature enough to digest hot dogs. To eat the hot dog safely, the child should
be sitting down, and the hot dog should be appropriately cut into irregularly shaped
pieces.
27. The clinic is lending a federally approved car seat to an infant's family. Where in the
car should the nurse explain is the safest place to put the car seat?
a. Front facing in back seat.
b. Rear facing in back seat.
c. Front facing in front seat if an air bag is on the passenger side.
d. Rear facing in front seat if an air bag is on the passenger side.
ANS: B
The rear-facing car seat provides the best protection for an infant's disproportionately
heavy head and weak neck. Infants should face the rear from birth to 20 lbs and as
close to 1 year of age as possible. The middle of the back seat provides the safest
position. Severe injuries and deaths in children have occurred from air bags deploying
on impact in the front passenger seat.
28. A nurse is teaching parents about prevention and treatment of colic. Which should
the nurse include in the teaching plan?
a. Avoid use of pacifiers.
b. Eliminate all secondhand smoke contact.
c. Lay infant flat after feeding.
d. Avoid swaddling the infant.
ANS: B
To prevent and treat colic, teach parents that if household members smoke, they should
avoid smoking near the infant; smoking activity should preferably be confined to outside
of the home. A pacifier can be introduced for added sucking. The infant should be
swaddled tightly with a soft, stretchy blanket, and placed in an upright seat after
feedings.
29. Parent guidelines for relieving colic in an infant include:
a. avoiding touching the abdomen.
b. avoiding using a pacifier.
c. changing the infant's position frequently.
d. placing the infant where the family cannot hear the crying.
ANS: C
Changing the infant's position frequently may be beneficial. The parent can walk holding
the infant face down and with the infant's chest across the parent's arm. The parent's
hand can support the infant's abdomen, applying gentle pressure. Gently massaging the
abdomen is effective in some infants. Pacifiers can be used for meeting additional
sucking needs. The infant should not be placed where monitoring cannot be done. The
infant can be placed in the crib and allowed to cry. Periodically, the infant should be
picked up and comforted.
30. Which clinical manifestations should cause the nurse to suspect that a child,
diagnosed with a digestive disorder, may be demonstrating signs of failure to thrive?
a. Avoidance of eye contact.
b. An associated malabsorption defect.
c. Weight that falls below the 15th percentile.
d. Normal achievement of developmental landmarks.
ANS: A
One of the clinical manifestations of nonorganic failure to thrive is the child's avoidance
of eye contact with the health professional. A malabsorption defect would result in a
physiologic problem, not behavioral. Weight (but not height) below the 5th percentile is
indicative of failure to thrive. Developmental delays, including social, motor, adaptive,
and language, exist.
31. Which consideration should be considered when planning care for an infant
diagnosed with failure to thrive?
a. Establishing a structured routine and follow it consistently.
b. Maintaining a nondistracting environment by not speaking to the infant during
feeding.
c. Placing the infant in an infant seat during feedings to prevent overstimulation.
d. Limiting sensory stimulation and play activities to alleviate fatigue.
ANS: A
The infant with failure to thrive should have a structured routine that is followed
consistently. Disruptions in other activities of daily living can have a great impact on
feeding behaviors. Bathing, sleeping, dressing, playing, and feeding are structured. The
nurse should talk to the infant by giving directions about eating. This will help the infant
maintain focus. Young children should be held while being fed, and older children can sit
at a feeding table. The infant should be fed in the same manner at each meal. The
infant can engage in sensory and play activities at times other than mealtime.
32. What is an important nursing responsibility when dealing with a family experiencing
the loss of an infant from sudden infant death syndrome (SIDS)?
a. Explain how SIDS could have been predicted and prevented.
b. Interview parents in depth concerning the circumstances surrounding the infant's
death.
c. Discourage parents from making a last visit with the infant.
d. Make a follow-up home visit to parents as soon as possible after the infant's death.
ANS: D
A competent, qualified professional should visit the family at home as soon as possible
after the death and provide the family with printed information about SIDS. An
explanation of how SIDS could have been predicted and prevented is inappropriate.
SIDS cannot be prevented or predicted. Discussions about the cause will only increase
parental guilt. The parents should be asked only factual questions to determine the
cause of death. Parents should be allowed and encouraged to make a last visit with
their infant.
33. With the goal of preventing plagiocephaly, the nurse should teach new parents to
consider which intervention?
a. Place the infant prone for 30 to 60 minutes per day.
b. Buy a soft mattress.
c. Allow the infant to nap in the car safety seat.
d. Have the infant sleep with the parents.
ANS: A
Prevention of positional plagiocephaly may begin shortly after birth by implementing
prone positioning or "tummy time" for approximately 30 to 60 minutes per day when the
infant is awake. Soft mattresses or sleeping with parents (co-sleeping) are not
recommended because they put the infant at a higher risk for a sudden infant death
incident. To prevent plagiocephaly, prolonged placement in car safety seats should be
avoided.
34. The parents of a 3-month-old infant report that their infant sleeps supine (face up)
but is often prone (face down) while awake. The nurse's response should be based on
what knowledge?
a. Unacceptable because of the risk of sudden infant death syndrome (SIDS).
b. Unacceptable because it does not encourage achievement of developmental
milestones.
c. Unacceptable to encourage fine motor development.
d. Acceptable to encourage head control and turning over.
ANS: D
These parents are implementing the guidelines to reduce the risk of SIDS. Infants
should sleep on their backs and then be placed on their abdomens when awake to
enhance development of milestones such as head control. The face-down position while
awake and positioning on the back for sleep are acceptable because they reduce risk of
SIDS and allow achievement of developmental milestones. These position changes
encourage gross motor, not fine motor development.
35. The nurse should teach parents that at what age it is safe to give infants whole milk
instead of commercial infant formula?
a. 6 months
b. 9 months
c. 12 months
d. 18 months
ANS: C
The American Academy of Pediatrics does not recommend the use of cow's milk for
children younger than 12 months. At 6 and 9 months, the infant should be receiving
commercial infant formula or breast milk. At age 18 months, milk and formula are
supplemented with solid foods, water, and some fruit juices.
36. A parent asks the nurse whether her infant is susceptible to pertussis. The nurse's
response should be based on which statement concerning susceptibility to pertussis?
a. Neonates will be immune the first few months.
b. If the mother has had the disease, the infant will receive passive immunity.
c. Children younger than 1 year seldom contract this disease.
d. Most children are highly susceptible from birth.
ANS: D
The acellular pertussis vaccine is recommended by the American Academy of
Pediatrics beginning at age 6 weeks. Infants are at greater risk for complications of
pertussis. The vaccine is not given after age 7 years, when the risks of the vaccine
become greater than those of pertussis. The infant is highly susceptible to pertussis,
which can be a life-threatening illness in this age-group.
1. In teaching parents about appropriate pacifier selection, the nurse should explain that
a pacifier should have which characteristics? (Select all that apply.)
a. Easily grasped handle
b. One-piece construction
c. Ribbon or string to secure to clothing
d. Soft, pliable material
e. Sturdy, flexible material
ANS: A, B, E
A good pacifier should be easily grasped by the infant. One-piece construction is
necessary to avoid having the nipple and guard separate. The material should be sturdy
and flexible. An attached ribbon or string and soft, pliable material are not
characteristics of a good pacifier.
2. In terms of gross motor development, what would the nurse educate the parents to
expect a 5-month-old infant to do? (Select all that apply.)
a. Roll from abdomen to back.
b. Put feet in mouth when supine.
c. Roll from back to abdomen.
d. Sit erect without support.
e. Move from prone to sitting position.
ANS: A, B
Rolling from abdomen to back and placing the feet in the mouth when supine are
developmentally appropriate for a 5-month-old infant. Rolling from back to abdomen is
developmentally appropriate for a 6-month-old infant. An 8-month-old infant should be
able to sit erect without support. A 10-month-old infant can usually move from a prone
to a sitting position.
3. A nurse is conducting education classes for parents of infants. The nurse plans to
discuss sudden infant death syndrome (SIDS). Which risk factors should the nurse
include as increasing an infant's risk of a SIDS incident? (Select all that apply.)
a. Breastfeeding
b. Low Apgar scores
c. Male sex
d. Birth weight in the 50th or higher percentile
e. Recent viral illness
ANS: B, C, E
Certain groups of infants are at increased risk for SIDS: those with low birth weight, low
Apgar scores, or recent viral illness, and those of male sex. Breastfed infants and
infants of average or above-average weight are not at higher risk for SIDS.
4. Which interventions should the nurse implement when caring for a family of a sudden
infant death syndrome (SIDS) infant? (Select all that apply.)
a. Allow parents to say goodbye to their infant.
b. Once parents leave the hospital, no further follow-up is required.
c. Arrange for someone to take the parents home from the hospital.
d. Avoid requesting an autopsy of the deceased infant.
e. Conduct a debriefing session with the parents before they leave the hospital.
ANS: A, C, E
An important aspect of compassionate care for parents experiencing a SIDS incident is
allowing them to say good-bye to their infant. These are the parents' last moments with
their infant, and they should be as quiet, meaningful, peaceful, and undisturbed as
possible. Because the parents leave the hospital without their infant, it is helpful to
accompany them to the car or arrange for someone else to take them home. A
debriefing session may help health care workers who dealt with the family and
deceased infant to cope with emotions that are often engendered when a SIDS victim is
brought into the acute care facility. An autopsy may clear up possible misconceptions
regarding the death. When the parents return home, a competent, qualified professional
should visit them after the death as soon as possible.
Question 11
An infant is being introduced to drinking fluids from a cup. The nurse instructs the
mother that fruit juice can now be added. Which of the following would the nurse
suggest the mother try first? Select all that apply.
• Pineapple
• White grape juice
• Apple
• Grapefruit
• Orange
• Apple
• White grape juice
Explanation:
Juice is introduced when a cup is introduced to an infant. Usually 4-6 ounces of juice is
recommended. Juices that have low-acidity like apple and white grape juice are
appropriate. These juices may be diluted to half-strength with water. Orange, grapefruit
and pineapple juice are to be avoided.
Question 12
The mother of a 3-month-old baby is concerned because the child is not able to sit
independently. How should the nurse respond to this mother's concern?
• Most babies sit steadily at 3 months.
• Most babies sit steadily at 4 months.
• Most babies do not sit steadily until 8 months.
• Sitting ability and the age of first tooth eruption are correlated.
• Most babies do not sit steadily until 8 months.
Explanation:
An 8-month-old child can sit securely without any additional support. Babies are not
able to sit steadily at age 3 or 4 months. Sitting ability does not correspond with tooth
eruption.
Question 13
The nurse is visiting a mother who has a 3-month-old infant who has been hospitalized
for cardiac problems. Which nursing diagnosis should the nurse use to guide care for
this family at this time?
• Disturbed maternal sleep pattern related to infant's feeding schedule
• Risk for impaired parenting related to hospitalization of infant
• Deficient knowledge related to normal infant growth and development
• Health-seeking behaviors related to adjusting to parenthood
• Risk for impaired parenting related to hospitalization of infant
Explanation:
The diagnosis appropriate for the family whose infant has been hospitalized would be
risk for impaired parenting related to hospitalization. There is no evidence to suggest
that the mother is not adjusting to parenthood. There is no information about the infant's
feeding schedule. There is no information to suggest the mother has a knowledge deficit
regarding normal infant growth and development.
Question 14
The nurse observes a new mother bathing her 9-month-old baby. Which observation
indicates that the experience is positive for both mother and infant?
• The baby is crying and screaming.
• The baby is reaching for the mother.
• The baby is trying to keep the legs from touching the water.
• The baby is moving the arms and hand and smiling.
• The baby is moving the arms and hand and smiling.
Explanation:
Bath time should be fun for an infant and can serve many functions. Especially during
the second half of the first year, a child enjoys poking at soap bubbles on the surface of
the water or playing with bath toys. Bath time also helps an infant learn different
textures and sensations and provides an opportunity to exercise and kick as well as a
good opportunity for a parent to touch and communicate with the child. Crying,
screaming, reaching for the mother, and trying to avoid touching the water indicates that
the bath experience is not positive for the baby or the mother.
Question 15
A nurse is providing health promotion education to a family of an 11-month-old infant
who is eating "finger foods." The nurse knows the parents understand the risk of infant
choking when they state which response below?
• "I can feed our baby popcorn."
• "I can feed our baby Cheerios."
• "I can feed our baby raisins."
• "I can feed our baby lollipops."
• "I can feed our baby Cheerios."
Explanation:
Cheerios are a good choice for finger-foods to promote finger-grasp fine motor
coordination and self-feeding. Ten to 12 months is a good age to promote self-eating as
infants move into mostly solid foods. Popcorn, raisins, and lollipops are choking hazard
foods for infants at this age.
Question 16
After the nurse provides education to new parents about appropriate sleeping habits for
infants, which statement by a parent would indicate to the nurse that teaching needs to
reoccur?
• "By keeping the room at a neutral temperature, I do not have to use blankets."
• "I have a crib in my room so that I can breastfeed my baby."
• "I will place my infant on the back to sleep every night."
• "My husband gave the baby a special bear that I will place in the crib."
• "My husband gave the baby a special bear that I will place in the crib."
Explanation:
The nurse should reinforce that stuffed animals, blankets, pillows, and soft mattresses
are suffocation hazards for infants.
Question 17
A mother calls the clinic every couple of weeks concerned that her infant is not
developing appropriately. What would be an appropriate nursing diagnosis for the nurse
to assign to this client?
• Ineffective role performance related to new responsibilities
• Social isolation related to lack of adequate social support
• Deficient knowledge related to normal infant growth and development
• Health seeking behaviors related to adjusting to parenthood
• Deficient knowledge related to normal infant growth and development
Explanation:
The client is demonstrating deficient knowledge related to normal growth and
development of her infant. The nurse should plan interventions that include teaching of
expected outcomes of growth and development.
Question 18
Which measures should receive priority in the care plan for an infant client who has
sensitive skin?
• Use only cloth diapers
• Change diapers frequently
• Use scented wipes with stool
• Use baby power with each change
• Change diapers frequently
Explanation:
The infant should be changed every 2-4 hours. It is best to use unscented wipes or
clear water to clean the infant with each change. Baby power should never be used as it
is an aspiration risk.
Question 19
A teen mom asks the discharge nurse if it is okay to sleep in bed with her baby. She
says her mom always did it with her siblings and it seemed okay. How should the nurse
respond?
• "Sure, you can do whatever you want, it is your baby."
• "Bed sharing is okay, just make sure the infant is between two people."
• "Baby can sleep in your room in an infant crib, but not in an adult bed."
• "Sure, you can, make sure you use a soft mattress for support."
• "Baby can sleep in your room in an infant crib, but not in an adult bed."
Explanation:
According to the 2016 recommendation by the American Academy of Pediatrics, infants
should sleep in the same bedroom as the parents, but on a separate firm surface, such
as a crib or bassinet, and never on a couch, armchair or adult bed, to decrease the risks
of sleep-related deaths.
Question 20
The nurse is teaching the parents of an infant about bathing. The nurse will inform the
parents to set the home hot water heater to which temperature?
• 115°F (46.1℃)
• 130°F (54.4℃)
• 135°F (57.2℃)
• 125°F (51.6℃)
• 115°F (46.1℃)
Explanation:
Water safety also includes ensuring the home hot water heater temperature is set to
less than 120°F (48.9°C) to prevent burns and scalding of the infant while bathing.
When the nurse discharges a new mom and infant, the nurses notices that the car seat
is in the front seat of the car. What is the appropriate response for the nurse to make
regarding the car seat?
• "You should never put the car seat in the front."
• "Let me go over car seat safety with you, so you can install your car seat properly."
• "With the car seat in front, you can keep an eye on your baby."
• "I see you have a car seat, that is great."
Correct response:
• "Let me go over car seat safety with you, so you can install your car seat properly."
Explanation:
The nurse should notice this is not the proper place for a car seat. The car seat should
be rear facing and in the center of the back seat of the car. The nurse would review car
seat safety with the mother and have her install the seat properly. The nurse should
provide written materials if available. The other responses are not appropriate and do
not ensure that proper installation will occur and that infant safety will be maintained.
A parent asks the nurse what symptoms to expect with normal teething in the infant.
How should the nurse respond?
• The infant's temperature may go as high as 102°F (38.9°C).
• The infant's gumline will be tender.
• The infant will be constipated for 2 days.
• The infant will not play or eat for 2 days.
Correct response:
• The infant's gumline will be tender.
Explanation:
Infants experience discomfort as the tooth emerges through the peridontal membrane
and from inflammation. When teething some infants become irritable, have excessive
drooling and like to bite on hard surfaces. To relieve discomfort the parent can apply ice
to the gums or use an over-the-counter topical anesthetic for infants. Some infatns will
refuse to eat or have poor sleeping due to the pain in the gums. There is not a definitive
timeframe for this to occur, and it does not happen in all infants. Fever, diarrhea, and
vomiting are signs of illness, not teething.
A nurse is talking to and making facial expressions at a 9-month-old baby girl during a
routine office visit. What is the most advanced milestone of language development that
the nurse should expect to see in this child?
• The infant squeals with pleasure
• The infant says "da-da" when looking at her father
• The infant imitates her father's cough
• The infant coos, babbles, and gurgles
Correct response:
• The infant says "da-da" when looking at her father
Explanation:
By 9 months, an infant usually speaks a first word: "da-da" or "ba-ba." The other
answers refer to earlier milestones in language development. In response to a nodding,
smiling face, or a friendly tone of voice, a 3-month-old infant will squeal with pleasure or
laugh out loud. By 4 months, infants are very "talkative," cooing, babbling, and gurgling
when spoken to. At 6 months, infants learn the art of imitating. They may imitate a
parent's cough, for example, or say "Oh!" as a way of attracting attention.
Question 4
The nurse is assessing Julie, a 3-month-old infant. Which developmental milestone
would the nurse expect?
• Julie loves to play "pat-a-cake".
• Julie can grasp a toy at will.
• Julie can hold her head erect and steady.
• Julie can sit by herself.
Correct response:
• Julie can hold her head erect and steady.
Explanation:
When an infant matures and grows they move through different developmental
milestones. A 3-month-old rolls over from back to side and holds the head erect and
steady and begins to replace the reflex grasp with voluntary grasping. Grasping a toy at
will occurs at about 6- to 7-months of age. Sitting without support occurs around 6
months. Playing pat-a-cake is characteristic of an 8- to 9-month-old.
Question 5
A home visit nurse is providing health promotion on safety to a family of a 1-week-old
infant. Which of the following statements by the parents indicates the need for further
teaching?
• "We will give our son a pacifier before placing him in his crib."
• "We will place our infant in a rear-facing car seat in the back seat of the car."
• "We will swaddle our son to keep him quiet and warm to sleep."
• "We will position our infant on his side for sleeping."
Correct response:
• "We will position our infant on his side for sleeping."
Explanation:
Infants should be placed on their backs for sleeping to reduce the risk of SIDS. All other
choices are safe infant practices.
A mother takes her 4-month-old to the doctor for a visit. She asks the nurse what type of
baby cereal she should buy now that her child is starting solid foods. How should the
nurse respond?
• "You should buy oat cereal."
• "You should buy barley cereal."
• "You should buy wheat cereal."
• "You should buy rice cereal."
Correct response:
• "You should buy rice cereal."
Explanation:
The rice cereal should be first. The infant should be monitored for food allergies by
following the rice cereal with oats, barley, and wheat. Wheat has the highest allergy
reaction in infants.
Question 2
In working with infants, the nurse would expect the posterior fontanel to be closed in an
infant who is which age?
• 3 months
• 3 weeks
• 6 weeks
• 1 month
Correct response:
• 3 months
Explanation:
The posterior fontanel is usually closed by the second or third month of life.
Question 3
The nurse is assessing a 4-month-old infant during a scheduled visit. Which findings
might suggest a developmental problem?
• The child does not say dada or mama.
• The child does not vocally respond to voices.
• The child never squeals or yells.
• The child does not babble.
Correct response:
• The child does not vocally respond to voices.
Explanation:
The fact that the child does not vocally respond to voices might suggest a
developmental problem. At 4 to 5 months of age most children are making simple vowel
sounds, laughing aloud, doing raspberries, and vocalizing in response to voices. The
child is too young to babble, squeal, yell, or say dada or mama.
Question 4
If the infant is following a normal pattern of dentition, the child would most likely have
how many teeth by the age of 14 months?
• 14 to 18 teeth
• Four teeth
• 24 teeth
• Six to 12 teeth
Correct response:
• Six to 12 teeth
Explanation:
The central incisors erupt between 6 and 12 months of age and lateral incisors erupt
between 9 and 13 months. The other lateral incisors erupt between 10 and 16 months,
so by age 14 months the infant could have up to 12 teeth.
Question 5
A new mother asks the nurse what she should look for when the baby starts to teethe.
What should the nurse explain to the mother?
• The child will have a high temperature.
• The child's gum line will be tender.
• The child will not play or eat for 2 days.
• The child will be constipated for 2 days.
Correct response:
• The child's gum line will be tender.
Explanation:
Gums are sore and tender before a new tooth breaks the surface. As soon as the tooth
is through, the tenderness passes. A high temperature is not a normal expectation with
teething and should be reported to the health care provider. The child may resist
chewing because of the sore gum; however, it may not last for 2 days. Playing may or
may not be affected. Constipation is not an expectation with teething.
The infant weighs 7 lb 4 oz (3,248 g) at birth. If the infant is following a normal pattern of
growth, what would be the expected weight for this child at the age of 12 months?
• 25 lb (11.3 kg)
• 21 lb 12 oz (9.9 kg)
• 14 lb 8 oz (6.6 kg)
• 28 lb 4 oz (12.8 kg)
• 21 lb 12 oz (9.9 kg)
Explanation:
The average weight of a newborn is 7.5 pounds. The infant gains about 30g each day.
By four months of age they have doubled their birthweight. By 1 year of age they have
tripled their birth weight and have grown 10 to 12 inches. 7lb 4 oz X 3= 21 lb 12 oz
Question 2
The nurse is assessing development of a 4-month-old boy during a well-child visit.
Which observation needs further investigation?
• The infant turns his head in the direction of a squeak toy.
• The infant shows interest in looking at near or high-contrast objects.
• The infant makes babbling sounds, coos, and smiles.
• The infant responds to his mother when he sees her but not at other times when she is
near.
• The infant responds to his mother when he sees her but not at other times when she is
near.
Explanation:
If the infant does not respond to his mother's voice, it could indicate hearing loss. Infants
recognize parents' voices from 1 month of age. It is normal for the infant to turn his head
in the direction of a squeak toy, to focus visually on near or high-contrast objects, and to
make babbling sounds but no words by this age. Infants develop a social smile at 2
months.
Question 3
A 6-month-old girl weighs 14.7 pounds (6.7 kg) during a scheduled check-up. Her birth
weight was 8 pounds (3.6 kg). What is the priority nursing intervention?
• Discussing the child's feeding patterns
• Talking about solid food consumption
• Increasing the number of breast-feedings
• Discouraging daily fruit juice intake
• Discussing the child's feeding patterns
Explanation:
Assessing the current feeding pattern and daily intake is the priority intervention. Talking
about solid food consumption may not be appropriate for this child yet. Discouraging
daily fruit juice intake or increasing the number of breastfeedings may not be necessary
until the situation is assessed.
Question 4
A 12-month-old seen at a walk-in clinic weighed 8 pounds 4 ounces (3.75 kg) at birth.
Weight now is 20 pounds 8 ounces (9.3 kg). The nurse determines:
• The child weighs more than expected for age.
• The child weighs the expected amount for age.
• The child weighs less than expected for age.
• The weight assessment is blatantly inaccurate.
• The child weighs less than expected for age.
Explanation:
Birth weight should triple by 12 months. The child should weigh near 24 pounds 12
ounces (11.25 kg). The child is underweight for age.
Question 5
A nurse is conducting a class for new mothers about infants and nutrition. One of the
women asks, "What is the best nutrition for my 3-month-old infant?" Which response by
the nurse would be most appropriate?
• "Iron fortified formula is necessary for the infant's growth"
• "Experts recommend soy milk as the preferred food.".
• "Human milk is the best nutrition for your child"
• "Rice cereal is the best because allergy risk is low. "
• "Human milk is the best nutrition for your child"
Explanation:
Human milk provides optimal nutritional support for a newborn and has recognized
prebiotic and anti-inflammatory effects that enhance biological wellness for the child.
Ingestion of human milk is known to aid the newborn's immature immune system.
Breastfeeding is the feeding method most encouraged by health care providers today,
resulting from the nutritional composition of the milk, the additional immunity it provides
the infant in the form of antibodies, and the fact that it has the most easily digestible
form of protein. Human milk is readily available, inexpensive, and encourages bonding
between the mother and infant. The AAP (2005a) recommends breastfeeding
exclusively (no supplemental formulas or baby foods) for approximately the first 6
months and supports continuing breastfeeding after foods are introduced to serve as
the child's milk source for the entire first year as long as it is mutually desired by the
infant and the mother. Parents should not offer low-iron milks (e.g., cow, goat, soy) to
their child until the child is at least 12 months old. Cow's or goat's milk can contributeto
anemia because both are deficient in iron. Infants should also never receive low-fat or
nonfat milk because these milks do not have the fat, calories, or ironneeded to support
the rapid growth and development that occurs at this age.
The infant weighs 6 lb 8 oz (2,912 g) at birth. If the infant is following a normal pattern of
growth, what would be an expected weight for this child at the age of 4 months?
• 16 lb (7.26 kg)
• 13 lb (5.9 kg)
• 10 lb 8 oz (4.76 kg)
• 15 lb 4 oz (6.92 kg)
• 13 lb (5.9 kg)
Explanation:
The average newborn weighs 7.5 pounds. They loose 10% of their birthweight over the
first week of life but regain it in about 10-14 days. Most infants double their birth weight
by 4 months of age and triple their birth weight by the time they are 1 year old.If the
baby weighed 6lb 8 oz at birth and doubled that weight at 4 months the infant should
weigh 13 lb (6 1/2 X 2= 13).
Question 3
The nruse is providing client education to the parent about bathing the infant. What
would be important to instruct the parent?
• Infants need a daily bath
• Soap lubricates and oils an infant's skin
• Never use soap on an infant's hair
• Bath time provides an opportunity for play
• Bath time provides an opportunity for play
Explanation:
The work of children is play. Play provides a natural way for the infant to learn. In early
infancy infants prefer their parents rather than toys. Parents can talk and sing to infants
during feeding, bathing, and changing diapers. Infants do not need a daily bath as long
as the diaper area is washed with diaper changes. Soap is actually drying to an infant's
skin. Washing the hair with soap can help remove excess oil.
Question 4
The nurse is promoting a healthy diet to guide a mother when feeding her 2-week-old
girl. Which is the most effective anticipatory guidance?
• Advocating iron supplements with bottle-feeding
• Advising fluid intake per feeding of 5 or 6 ounces
• Discouraging the addition of fruit juice to the diet
• Substituting cow's milk if breast milk is not available
• Discouraging the addition of fruit juice to the diet
Explanation:
Discouraging the addition of fruit juice to the child's diet is the most effective anticipatory
guidance. Fruit juice can displace important nutrients from breast milk or formula. Cow's
milk is likely to result in an allergic reaction. If breast milk is not available, infant formula
may be substituted. Advising fluid intake per feeding of 5 or 6 ounces is too much for
this neonate, but is typical for an infant 4 to 6 months of age. Advocating iron
supplements with bottle-feeding is unnecessary so long as the formula is fortified with
iron.
The infant measures 21.5 in. (54.6 cm) at birth. If the infant is following a normal pattern
of growth, what would be an expected height for this child at the age of 6 months?
• 32 in. (81.3 cm)
• 29 in. (73.7 cm)
• 30.5 in. (77.5 cm)
• 27.5 in. (69.9 cm)
• 27.5 in. (69.9 cm)
Explanation:
Infants gain about 1/2 to 1 inch in length for the first 6 months of life. Therefore, a 21.5
inch baby adding 6 inches of growth would be 27.5 inches. Babies grow the fastest
during the first 6 months of life and slow down the second 6 months. By 12 months of
age, the infant's length has increased by 50 percent, making this child 32.25 inches at 1
year old.
Question 3
During an assessment, the nurse determines that a 3-month-old baby has a Moro
reflex. What does this finding indicate to the nurse?
• Most 3-month-olds still have a Moro reflex.
• It will persist until the age of 1 year.
• It usually lasts until 9 months.
• If present at 3 months of age, a neurologic exam is needed.
• Most 3-month-olds still have a Moro reflex.
Explanation:
The Moro reflex will begin to fade at age 5 months and disappear by age 6 months. A
Moro reflex at age 9 months or 1 year indicates the need for a neurologic examination.
Question 4
The nurse in a community clinic is assessing a 4-week-old infant. The mother asks if the
infant is developing normally. The nurse refers to which finding as suggestive of normal
development in infants from birth to 4 weeks of age?
• The infant frowns and tears are produced.
• The infant raises head and chest while on stomach
• The infant pulls self with arms.
• The infant makes babbling sounds.
• The infant raises head and chest while on stomach
Explanation:
Infants have gained some neck control and can independently raise head and chest by
4 weeks of age. Appearance of tears, pulling themselves with their arms, and making
babbling sounds are appropriate developmental milestones after 6 weeks of age.
TODDLER
A group of caregivers of toddlers are discussing the form of discipline in which the child
is placed in a "time-out" chair. Which statement made by these caregivers is most
appropriate related to this form of discipline?
"When my son starts getting frustrated and aggressive, I remind him that if he throws a
fit he will have to go to time out."
A toddler's mother tells you that no matter what she asks of her child, he says, "No." A
suggestion you might make to help her handle this problem is for her to:
give him secondary, not primary, choices.
00:03
01:01
The nurse is observing a 3-year-old boy in a day care center. Which behavior might
suggest an emotional problem?
Has persistent separation anxiety
The nurse is assessing a 2-year-old boy during a well child visit. The nurse correctly
identifies the child's current stage of Erickson's growth and development as:
Autonomy versus shame and doubt
The nurse is discussing the activities of a 20-month-old child with his mother. The
mother reports the children of her friends seem to have more advanced speech abilities
than her child. After assessing the child, which finding is cause for follow up?
Understands approximately 200 words
The father of a toddler reports his son says "no" every time he attempt to correct him.
What is the best advice can the nurse offer to the parent?
Saying no is your son's way of trying to exert his independence and is expected.
The nurse is supervising a play group of children on the unit. The nurse expect the
toddlers will most likely be involved in which activity?
Playing with the plastic vacuum cleaner and pushing it around the room
Parents of 3-year-old son ask the nurse for suggestions on how to deal with their son's
nightmares. Which suggestion would be least effective?
Talk to him that night about the details of the dreams.
A 2-year-old holds his breath until he passes out when he wants something his mother
does not want him to have. You would base your evaluation of whether these temper
tantrums are a form of seizure on the basis that:
seizures are not provoked; temper tantrums are.
When assessing a toddler's language development, what is the standard against which
you measure language in a 2-year-old?
He should speak in two-word sentences ("Me go").
Parents and their 35-month-old child have returned to the clinic for a follow-up
appointment. Which of the findings may signal a speech delay?
Uses two-word sentences or phrases
The father of a 2-year-old girl tells the nurse that he and his wife would like to begin
toilet training their daughter soon. He asks when the right time is to begin this process.
What should the nurse say in response?
"When she starts tugging on a wet or dirty diaper, she is letting you know she's ready."
00:02
01:01
The nurse is discussing sensory development with the mother of a 2-year-old boy.
Which parental comment suggests the child may have a sensory problem?
"He doesn't respond if I wave to him."
Which action is appropriate to enhance a child's self-esteem?
Include the child in activities that interest the adult.
By what age should the child know his/her own gender?
3
After teaching the mother of a 13-month boy old about suggestions for bathing and
hygiene, the nurse determines that the teaching was successful when the mother
states:
"It might be best to give him a bath in the evening."
During the toddler years, the child attempts to become autonomous. Which statement
by a 3-year-old's caregiver indicates that the child is developing autonomy?
"My child uses the potty chair and is dry all day long."
The toddler grows about how many inches in height per year?
3 inches
A mother expresses surprise to the nurse that her toddler daughter has begun
masturbating. The most important initial nursing response is that:
This is a normal and expected activity best treated matter-of-factly.
The parents of a 2-year-old boy report to the nurse because their child is "such a picky
eater." Which recommendation would be most helpful for developing healthy eating
habits in this child?
Offering a variety of foods along with the foods the child likes
Which gross motor developmental milestone is least likely for a 2 year old?
Rides a tricycle
What is a true statement regarding developmental milestones of the 30-month-old?
Full set of primary teeth
While observing a 13-month-old and her parents in the playroom of the hospital unit, the
nurse notes that the toddler is using her index finger to point towards a toy. How should
the nurse respond?
"Your daughter is demonstrating fine motor skills appropriate to her age by pointing with
her index finger."
The nurse is assessing a 2-year-old toddler. Which observations would alert the nurse
that the child may be developmentally delayed? Select all that apply.
The child's vocabulary consists of the words "ball", "dadda", "mum", "drink", and "up."
The child will not pick up a toy or touch the nose when directed by the nurse.
A 3-year-old child is seen at the clinic for a check up. When collecting information from
the child's mother she reports concern about her child's stools. She states he
sometimes passes what appears to be undigested food. What response by the nurse is
most appropriate?
"The digestive tracts of toddlers are not totally mature causing this to happen."
The nurse finds the diet of a 30-month-old girl to be low in calcium. What suggestion
can significantly increase this toddler's calcium intake?
Give her slices of cheddar cheese as a snack.
A nurse is discussing safety measures with the parents of a toddler. What would the
nurse emphasize to address the most frequent type of accident in toddlers?
"Keep all cleaning products and drugs out of the reach of your child."
A mother of a 2-year-old asks the nurse, "What would be a good between-meal snack?"
What foods would be appropriate for the nurse to suggest? Select all that apply.
Pieces of apples
Orange slices
Cheese
Yogurt
During a well-child visit, the nurse observes the child saying "no" to her mother quite
frequently. The mother asks the nurse, "How do I deal with her saying no all the time?"
What would be appropriate for the nurse to suggest? Select all that apply.
"Limit the number of questions you ask of her."
"Make a statement instead of asking a question."
"Offer her two options from which to choose."
The nurse is observing a 36-month-old boy during a well-child visit. Which motor skill
has he most recently acquired?
Undress himself
The nurse is reviewing sleep and rest activities of a 16-month-old child with the parents.
The father states, "I have told my wife it is unhealthy for our child to sleep with us. It's
time for him to sleep in his own bed. What do you think?" What is the nurse's best initial
response?
"It must be difficult for the two of you to both feel strongly about what is best for you and
your child."
The nurse is caring for a 18-month-old child who has had surgery. The medical record
indicates the child weighs 23 pounds (10.45 kg). When monitoring his urinary output the
nurse is aware that normal hourly output should be what value?
10 mL
Terms in this set (16)
OriginalAlphabetical
1.
When assessing the oral cavity of a 2.5-year-old toddler, which finding is expected?
A)
12 deciduous teeth
B)
20 deciduous teeth
C)
16 deciduous and 2 permanent teeth
D)
6 deciduous and 12 permanent teeth
B
Feedback:
All 20 deciduous teeth are generally present by 2.5 to 3.0 years of age.
2.
The nurse is preparing a community educational program for the parents of toddlers.
Which topics should the nurse include that address the 2020 National Health Goals for
safety? (Select all that apply.)
A)
Using age-appropriate car seats
B)
Securing poisonous items out of reach
C)
Eliminating lead-based paint in the home
D)
Removing pets from the home environment
E)
Obtaining foot stools for use during toilet training
A, B, C
Feedback:
The 2020 National Health Goals for toddlers focus on safety. The nurse can help the
nation achieve these goals by educating parents about the importance of using car
seats and childproofing the home against poisoning and lead poisoning. The National
Health Goals do not address pets in the home. Foot stools for toilet training are not a
safety concern.
3.
The parents of a toddler want to assist the child achieve the developmental task of
autonomy. Which approach should the nurse suggest to the parents?
A)
Teach the child how to count.
B)
Allow the child to make simple decisions.
C)
Give the child small household chores to do.
D)
Urge the child to put on clothes independently.
B
Feedback:
To develop a sense of autonomy is to develop a sense of independence. A healthy level
of autonomy is achieved when parents are able to balance independence with
consistently sound rules for safety. Allowing the child to make simple decisions helps
the child achieve autonomy in a safe setting. Teaching how to count will not help
develop autonomy in the child. Providing the child with chores will not develop
autonomy. The child is not developmentally prepared to be able to put on clothes
independently.
4.
A mother is concerned that her 2-year-old child is having seizures when he holds his
breath until he passes out when he wants something his mother does not want him to
have. What should the nurse respond to this mother's concern?
A)
Seizures rarely occur in toddlers.
B)
With seizures, cyanosis rarely develops.
C)
Seizures are not provoked; temper tantrums are.
D)
Seizures typically occur with fever; temper tantrums do not.
C
Feedback:
Some children hold their breath as part of a temper tantrum until they become cyanotic.
Breath holding occurs when a child is provoked; the child develops a distended chest,
often has air-filled cheeks, and shows increasing distress as the body registers oxygen
want. A seizure cannot be provoked. Seizures can occur in all ages. Cyanosis can
occur with seizures. Seizures can occur in those with neurologic problems and not just
with a fever.
5.
The nurse had instructed the family of a toddler on home safety during a previous visit.
During this current visit, what observation indicates that instruction has been effective?
A)
Prescribed medication sitting on countertop
B)
House plant on a small table next to the sofa
C)
Small bowl of mixed nuts on the coffee table
D)
All windows in the home have locked screens.
D
Feedback:
To prevent falls, the parents should keep the house windows closed or keep secure
screens in place. Prescribed medication should be stored in a locked cabinet and not
left out on a table because this could cause accidental poisoning. House plants should
not be within reach of the toddler because this could cause an accidental poisoning or
injury if the plant is pulled on top of the child. Nuts could cause accidental choking and
should not be within the child's reach.
6.
The parents of a toddler plan to begin toilet training. Which instruction should the nurse
provide to the parents at this time?
A)
Toilet training is a 12-month process.
B)
Bowel training is easier than urine training.
C)
All children should be toilet trained by age 2 years.
D)
Children can remain dry during the night before they can do so during the day.
B
Feedback:
Training should begin with defecation training because this is an easier concept for the
child to grasp. There is no time limit regarding the amount of time it takes to toilet train a
toddler. Even though theoretically a child can begin toilet training once able to walk, the
child needs to reach specific milestones before being able to successfully toilet train.
Children are more likely to remain dry during the day than during the night.
7.
The nurse is determining a toddler's language development. What is an expected
finding for language development in a 2-year-old?
A)
Able to count out loud to 20
B)
Speaks 20 nouns and 4 pronouns
C)
Speaks two words plus "ma-ma" and "da-da"
D)
Speaks in two-word sentences using a noun and a verb
D
Feedback:
A 2-year-old child should be speaking in simple two-word sentences using a noun and a
verb. Any 2-year-old child who does not talk in two-word, noun-verb simple sentences
needs a careful assessment to determine the cause because this is beyond a point of
normal development. Counting is not an expectation for a 2-year-old child. The child will
not be able to speak 20 nouns and 4 pronouns.
8.
The nurse observes a toddler riding a tricycle and decides that the parents need
additional safety education. What did the nurse observe?
A)
Toddler wearing a helmet
B)
Toddler wearing long pants
C)
Toddler wearing tennis shoes
D)
Toddler not wearing a helmet
D
Feedback:
Toddlers need to wear a helmet as soon as they begin riding a tricycle. Parents are not
as conscientious about using helmets as they are for bicycle riding so this is an area
where health teaching is necessary. Wearing a helmet would be expected, and the
nurse would not need to provide additional safety education for the parents. Long pants
and tennis shoes do not pose a safety issue.
9.
The mother of a toddler is frustrated because no matter what she asks of the child, the
response is "no." What can the nurse suggest to the mother to assist with this problem?
A)
Pretend she does not hear the child.
B)
Ask no further questions to the child.
C)
Tell the child to never to say "no" again.
D)
Give the child secondary, not primary, choices.
D
Feedback:
A toddler needs experience in making choices, and to provide the opportunity to do this,
a parent could give a secondary choice. Pretending not to hear the child, asking no
further questions, and telling the child to never say "no" again will not help with the
toddler's obstinacy.
10.
The mother of a toddler is frustrated because the toddler insists on brushing his own
teeth and being left alone in the bathtub. What advice should the nurse provide to the
mother about these expectations?
A)
Helping with toothbrushing encourages autonomy.
B)
It is unusual for a 2-year-old to have such strong opinions.
C)
The mother should continue to give full care in all aspects.
D)
Leaving alone in the bathtub is a good way to encourage autonomy.
A
Feedback:
Toddlers need a toothbrush they recognize as their own. Toward the end of the toddler
period, they can begin to do the brushing themselves under supervision; although,
almost all children need some supervision until about age 8 years. It is not unusual for a
toddler to have opinions and want to do things themselves. The mother needs to permit
the child to perform autonomous acts with supervision. The child is too young to be
permitted in the bathtub alone. This is a safety hazard.
The mother of a toddler is concerned because the child has taken the wheels off of a
toy truck and placed them in a sandbox as stepping stones to walk. What should the
nurse explain about this child's behavior?
A)
This is assimilation.
B)
The child does not like toy trucks.
C)
The number of toys should be limited.
D)
This is abnormal and needs to be evaluated.
A
Feedback:
At the end of the toddler period, children enter a second major period of cognitive
development termed preoperational thought and begin to use a process termed
assimilation. This is when the child learns to change a situation and is what causes
toddlers to use toys in the "wrong" way such as taking the wheels off of a truck and
using them as stepping stones. The child has changed the toy's use to fit his or her
thoughts or used assimilation. This behavior does not mean that the child does not like
toy trucks. The number of toys does not need to be limited. This behavior is not
abnormal but expected.
12.
The mother of a toddler observes the child play next to another child but not with the
child. What should the nurse explain to the mother about this type of play behavior?
A)
This is peer play and is abnormal.
B)
This is parallel play and is expected.
C)
This is premature play and should be stopped.
D)
This is adjacent play and is only seen in school-age children.
B
Feedback:
All during the toddler period, children play beside children next to them, not with them.
This side-by-side play called parallel play is not unfriendly but is a normal
developmental sequence that occurs during the toddler period. This is not peer,
adjacent, or premature play. This behavior is not abnormal, does not need to be
stopped, and is not seen in school-age children.
13.
The nurse is preparing to assess a toddler during a routine health maintenance visit.
Which assessment will the nurse perform to determine the child's growth milestone?
A)
Blood pressure
B)
Urine specimen
C)
Hemoglobin level
D)
Height and weight
D
Feedback:
Growth milestones are assessed at every health maintenance visit and are determined
by measuring height and weight. Blood pressure does not assess a growth milestone. A
urine specimen would be done at specific times. A hemoglobin level would be
determined during specific times. Urine specimens and hemoglobin levels do not
measure growth milestones.
14.
A mother brings a 15-month-old child to the clinic for a routine health maintenance visit.
Which immunization should the nurse prepare to administer to this child?
A)
MMR
B)
Rinne test
C)
Oral polio
D)
Hepatitis A
A
Feedback:
The measles-mumps-rubella (MMR) vaccine is administered at either the 12-month or
15-month visit. Rinne test is not an immunization but rather a test for hearing. The oral
polio vaccination is not listed as an immunization needed for toddlers. Hepatitis A
vaccination is given at either the 12-month or 18-month visit.
15.
The mother of a 2-year-old child tells the nurse that she is constantly scolding the child
for having wet pants. The child was toilet trained at 12 months, but since walking, the
child wets all of the time. Which nursing diagnosis should the nurse use guide
instruction for the mother?
A)
Total urinary incontinence related to delayed toilet training
B)
Excess fluid volume related to inability to control urination
C)
Ineffective coping related to lack of self-control of 2-year-old
D)
Deficient parental knowledge related to inappropriate method for toilet training
D
Feedback:
The mother is having difficulty understanding the principles of toilet training. The
diagnosis of deficient parental knowledge about toilet training is the most appropriate for
the nurse to use to guide instruction for the mother. The child is not experiencing total
urinary incontinence. The child does not have an excess in fluid volume. The mother is
not demonstrating ineffective coping.
16.
The parents of a toddler are worried that the child is not eating enough because food is
always left on the child's plate. What should the nurse encourage the parents to do?
A)
Place smaller amount on the child's plate.
B)
Reinforce that the child is to eat everything on the plate.
C)
Discipline the child for not eating by removing a toy from play.
D)
Feed the child if refusing to eat the food on the plate independently.
A
Feedback:
Because the actual amount of food eaten daily varies, the parents should be instructed
to place a small amount of food on a plate and allow their child to eat it and ask for more
rather than serve a large portion the child cannot finish. Cleaning a plate gives a child a
feeling of independent functioning, whereas leaving food uneaten suggests parents
expected something more. Allowing self-feeding is a major way to both strengthen
independence in a toddler and improve the amount of food consumed. Most toddlers
insist on feeding themselves and generally will resist eating if a parent insists on feeding
them. An individual child may react to repeated attempts at being fed by refusing to eat
at all. The child does not need discipline.
Pre-School Child
1. The nurse is identifying outcomes for a family with a preschool-age child who has
broken fluency. Which outcome would be the most appropriate for this family?
A) The parents will not call attention to the child's broken fluency.
B) The mother will encourage the child to practice speaking in the home.
C) The other children will help the child by finishing words and sentences.
D) The mother will correct the child only when other family members are absent.
Ans: A
Feedback:
Calling attention to broken fluency can make the situation worse. The child should not
be encouraged to speak if he or she does not want to. The parents should intercept any
children who desire to finish the child with broken fluency's words or sentences. The
child should not be punished or corrected for broken fluency because this is a normal
part of speech development.
2. The nurse is helping parents develop the developmental task of initiative in their
preschool-age child. Which activity should the nurse suggest the parents implement?
A) Teach the child street-crossing safety.
B) Help the child learn how to follow rules.
C) Allow the child to experiment with molding clay.
D) Provide the child with clothes that snap rather than button.
.
Ans: C
Feedback:
To gain a sense of initiative, preschoolers need exposure to a wide variety of play
materials so they can learn as much about how things work as possible. The parents
should be urged to provide play materials that encourage creative play such as
modeling clay. Any experience with free-form play is helpful. Street-crossing safety,
following rules, and providing clothes that snap will not support the developmental task
of initiative as much as providing a substance to experiment during play
3. The nurse is preparing an educational program for parents of preschool-age children
to promote personal safety. Which information should the nurse include in this program?
(Select all that apply.)
A) Reducing the intake of fast-food items
B) Limiting exposure to household chores
C) Chewing food thoroughly before swallowing
D) Explaining who police are and what they look like
E) Teaching to never talk with or accept a ride from a stranger
Ans: D, E
Feedback:
To promote personal safety in the preschool-age child, the nurse should instruct families
to explain the role and purpose of police to the child and teach to never talk to or accept
a ride from a stranger. Reducing the intake of fast-food items will help with weight
control. Limiting exposure to household chores has no identified value. Chewing food
thoroughly before swallowing can help with digestion and weight control.
4. The nurse is caring for a preschool-age child who needs a CT scan. Which action
should the nurse use to best prepare the child for this diagnostic test?
A) Tell the child to follow directions to avoid being hurt.
B) Help the child to pretend that the CT scan machine is a camera.
C) Explain that the child must behave because the technician is busy.
D) Tell the child that the CT scan is a picture of the dark parts inside the body.
Ans: B
Feedback:
Because preschoolers' imagination is so active, this leads to several fears such as fear
of the dark and mutilation. The nurse needs to help the child understand that the CT
scanner is like a camera to take pictures of the body parts. Threatening the child to
follow directions or becoming hurt plays into the child's fear of mutilation. Telling the
child to behave creates a fear of punishment. Telling the child that the CT scan is a
picture of the body's dark parts plays into the child's fear of the dark.
5. Which type of play should the nurse encourage for a preschool-age child that is
hospitalized?
A) Playing an electronic handheld game
B) Dressing in the mother's coat to play house
C) Turning out the lights to play hide and seek
D) Planting flower bulbs that can be watched growing next spring
Ans: B
Feedback:
Preschool-age children have active imaginations and dressing up to play house would
be an appropriate play activity for the nurse to encourage. The child's fine motor skills
are not developed to play an electronic handheld game. Children of this age are afraid
of the dark so turning out the lights to play hide and seek is not appropriate. Planting
flower bulbs is an activity that is too long-term for this age range.
6. Which immunization should the nurse plan to administer to a preschooler during a
health maintenance visit?
A) DTaP
B) Influenza
C) Hepatitis B
D) Tetanus booster
Ans: B
Feedback:
Influenza vaccination would be administered annually. The diphtheria, pertussis, and
tetanus (DTaP) vaccination should be provided before the child starts school. Hepatitis
B and tetanus booster are not identified as vaccinations appropriate for this age group.
7. The mother of a female preschool-age child is concerned that the child is developing
an unhealthy attachment to her father. About which behavior should the nurse instruct
the mother?
A) Electra complex
B) Oedipus complex
C) Freudian complex
D) Sexual identification complex
Ans: A
Feedback:
An Electra complex is the attachment of a preschool girl to her father. This phenomenon
in preschoolers is a normal part of maturing. Oedipus complex is the attachment of a
preschool-age boy to his mother. There is not one specific Freudian complex. There is
not an identified sexual identification complex.
8. A preschool-age child tells the nurse about an imaginary friend. The parents are
concerned because the child refuses to do anything without the friend's help. Which
nursing diagnosis is most applicable for the family?
A) Compromised family coping related to abnormal behavior of child
B) Disturbed thought processes related to deep-set psychological need
C) Parental anxiety related to lack of understanding of childhood development
D) Social isolation related to unwillingness to relate except through imaginary friend
Ans: C
Feedback:
The parents need to understand that the child's behavior is not uncommon. Imaginary
friends are common in the preschool-age child. The child's behavior is not abnormal.
The child does not have a deep-set psychological need. The child is not at risk for social
isolation.
9. The nurse is observing the behavior of a preschool-age child and becomes
concerned. Which observation suggests that the child's thinking is inconsistent with
normal preschooler growth and development?
A) Refusing to play with "real" children
B) Refusing to go to bed without the friend
C) Insisting that an imaginary friend have dinner with the family
D) Insisting that an imaginary friend watch television with the child
Ans: A
Feedback:
Many preschoolers have an imaginary friend who plays with them. Imaginary friends are
a normal, creative part of the preschool years and can be invented by children who are
surrounded by real playmates as well as by those who have few friends. As long as the
child has exposure to real playmates and imaginary, do not take center stage in the
child's life or prevent them from socializing with other children; the imaginary friend
should not pose a problem. Refusing to go to bed without the friend, having the friend
eat dinner with the family, and watching television with the imaginary friend are all
acceptable behaviors by the preschool-age child.
10. During an assessment, a preschool-age child tells the nurse about having 12
siblings. The nurse is aware that the child has two older brothers. What should the
nurse respond to this child?
A) "I guess you don't know much about counting yet."
B) "Don't lie to me. That's never a nice thing to do to someone."
C) "Does it make you feel more important when you add on brothers?"
D) "That is a good pretend answer but tell me the names of the brothers you really
have."
Ans: D
Feedback:
Stretching stories to make them seem more interesting is a phenomenon frequently
encountered in preschoolers. This kind of storytelling should not be encouraged. The
child should be helped to separate fact from fiction. The nurse should ask the child to
say the names of the brothers the child really has. The nurse should not insult the
child's counting ability. The nurse should not accuse the child of lying or making the
child seem more important by having more brothers.
11. A community health center is planning a seminar about the 2020 National Health
Goals for preschool-age children. Which topics should be included in this seminar to
address safety? (Select all that apply.)
A) Protection against secondhand smoke
B) Providing helmets before riding a bicycle
C) Using appropriate restraints in motor vehicles
D) Removing houseplants from easy to reach areas
E) Posting the telephone number of the poison control agency
Ans: A, B, C
Feedback:
The 2020 National Health Goals for preschool-age children focus on safety and include
protecting preschoolers against secondhand smoke, using recommended automobile
restraints, and fitting children with helmets before beginning bicycle riding. Removing
houseplants and posting the telephone number of the poison control agency would be
appropriate for families with toddlers.
12. The mother of a preschool-age child is pregnant and wants to enroll the child in a
child care program. When should the nurse suggest that the child be enrolled in this
program?
A) By 4 years of age regardless of the pregnancy
B) Now after explaining that the new sibling will take up the mother's time
C) Three months before the baby is born, after the mother stresses that he is growing
up
D) Immediately after the baby is born so that the child will feel less jealous and more
secure
Ans: C
Feedback:
If children are to start preschool or child care, it's best if they can do so either before the
new baby is born or 2 or 3 months afterward. That way, children can perceive starting
school as a result of maturity and not of being pushed out of the house by the new child.
There is no time limit about when a child should start preschool. The mother should not
explain to the child that the new baby will be taking up all of the mother's time.
00:02
01:01
13. The parents of a preschool-age child are investigating child care centers to enroll
the child. What should the nurse review with the parents prior to them making a
decision? (Select all that apply.)
A) Ask about the child-staff ratio.
B) Ask about the center's payment plan.
C) Find out if parents can visit at any time.
D) Find out how long the center has been in operation.
E) Ask about the center's licenses and compliance with regulations.
Ans: A, C, D, E
Feedback:
When investigating child care centers, the nurse should counsel the parents to find out
about the child-staff ratio, parental visiting hours, the time the center has been in
operation, and compliance with licenses and regulations. The payment plan might be
important to the parents; however, it should not be the sole factor in making a decision
about a child care center.
14. The nurse instructs a mother on actions to prevent sibling rivalry between a
preschool-age child and a newborn. Which observation indicates that instruction has
been effective?
A) Mother sleeps while the newborn is sleeping.
B) Mother asks if the preschool-age child likes the new baby.
C) Mother sets aside afternoon time for the preschool-age child while the baby naps.
D) Mother suggests family not bring gifts to the preschool-age child until behavior
changes.
Ans: C
Feedback:
To help reduce sibling rivalry, the mother should set aside afternoon time for the
preschool-age child while the baby naps. Sleeping when the baby sleep, asking if the
preschool-age child likes the baby, and limiting gifts to the preschool-age child until
behavior changes will promote sibling rivalry.
15. The parents of a preschool-age child want to begin preparing the child to attend
school. What should the nurse suggest the parents discuss with the child to help with
this preparation?
A) Point out how to go to school.
B) Talk about school as an enjoyable experience.
C) Warn about how many rules there will be in school.
D) Encourage working on projects lying on the floor so school tables will be appreciated.
Ans: B
Feedback:
If school is discussed as something to look forward to, as an adventure that will be
satisfying and rewarding, a child comes to look forward to it as a positive experience.
Pointing out how to get home from school might be more important than how to get to
school. Warning about rules and expecting to work on the floor may cause the child to
view school as punishment.
The nurse is identifying outcomes for a family with a preschool-age child who has
broken fluency. Which outcome would be the most appropriate for this family?
A) The parents will not call attention to the child's broken fluency.
B) The mother will encourage the child to practice speaking in the home.
C) The other children will help the child by finishing words and sentences.
D) The mother will correct the child only when other family members are absent.
A) The parents will not call attention to the child's broken fluency.
Calling attention to broken fluency can make the situation worse. The child should not
be encouraged to speak if he or she does not want to. The parents should intercept any
children who desire to finish the child with broken fluency's words or sentences. The
child should not be punished or corrected for broken fluency because this is a normal
part of speech development.
The nurse is helping parents develop the developmental task of initiative in their
preschool-age child. Which activity should the nurse suggest the parents implement?
A) Teach the child street-crossing safety.
B) Help the child learn how to follow rules.
C) Allow the child to experiment with molding clay.
D) Provide the child with clothes that snap rather than button.
C) Allow the child to experiment with molding clay.
To gain a sense of initiative, preschoolers need exposure to a wide variety of play
materials so they can learn as much about how things work as possible. The parents
should be urged to provide play materials that encourage creative play such as
modeling clay. Any experience with free-form play is helpful. Street-crossing safety,
following rules, and providing clothes that snap will not support the developmental task
of initiative as much as providing a substance to experiment during play.
The nurse is preparing an educational program for parents of preschool-age children to
promote personal safety. Which information should the nurse include in this program?
(Select all that apply.)
A) Reducing the intake of fast-food items
B) Limiting exposure to household chores
C) Chewing food thoroughly before swallowing
D) Explaining who police are and what they look like
E) Teaching to never talk with or accept a ride from a stranger
D) Explaining who police are and what they look like
E) Teaching to never talk with or accept a ride from a stranger
To promote personal safety in the preschool-age child, the nurse should instruct families
to explain the role and purpose of police to the child and teach to never talk to or accept
a ride from a stranger. Reducing the intake of fast-food items will help with weight
control. Limiting exposure to household chores has no identified value. Chewing food
thoroughly before swallowing can help with digestion and weight control.
The nurse is caring for a preschool-age child who needs a CT scan. Which action
should the nurse use to best prepare the child for this diagnostic test?
A) Tell the child to follow directions to avoid being hurt.
B) Help the child to pretend that the CT scan machine is a camera.
C) Explain that the child must behave because the technician is busy.
D) Tell the child that the CT scan is a picture of the dark parts inside the body.
B) Help the child to pretend that the CT scan machine is a camera.
Because preschoolers' imagination is so active, this leads to several fears such as fear
of the dark and mutilation. The nurse needs to help the child understand that the CT
scanner is like a camera to take pictures of the body parts. Threatening the child to
follow directions or becoming hurt plays into the child's fear of mutilation. Telling the
child to behave creates a fear of punishment. Telling the child that the CT scan is a
picture of the body's dark parts plays into the child's fear of the dark.
Which type of play should the nurse encourage for a preschool-age child that is
hospitalized?
A) Playing an electronic handheld game
B) Dressing in the mother's coat to play house
C) Turning out the lights to play hide and seek
D) Planting flower bulbs that can be watched growing next spring
B) Dressing in the mother's coat to play house
Preschool-age children have active imaginations and dressing up to play house would
be an appropriate play activity for the nurse to encourage. The child's fine motor skills
are not developed to play an electronic handheld game. Children of this age are afraid
of the dark so turning out the lights to play hide and seek is not appropriate. Planting
flower bulbs is an activity that is too long-term for this age range.
Which immunization should the nurse plan to administer to a preschooler during a
health maintenance visit?
A) DTaP
B) Influenza
C) Hepatitis B
D) Tetanus booster
B) Influenza
Influenza vaccination would be administered annually. The diphtheria, pertussis, and
tetanus (DTaP) vaccination should be provided before the child starts school. Hepatitis
B and tetanus booster are not identified as vaccinations appropriate for this age group.
The mother of a female preschool-age child is concerned that the child is developing an
unhealthy attachment to her father. About which behavior should the nurse instruct the
mother?
A) Electra complex
B) Oedipus complex
C) Freudian complex
D) Sexual identification complex
A) Electra complex
An Electra complex is the attachment of a preschool girl to her father. This phenomenon
in preschoolers is a normal part of maturing. Oedipus complex is the attachment of a
preschool-age boy to his mother. There is not one specific Freudian complex. There is
not an identified sexual identification complex.
A preschool-age child tells the nurse about an imaginary friend. The parents are
concerned because the child refuses to do anything without the friend's help. Which
nursing diagnosis is most applicable for the family?
A) Compromised family coping related to abnormal behavior of child
B) Disturbed thought processes related to deep-set psychological need
C) Parental anxiety related to lack of understanding of childhood development
D) Social isolation related to unwillingness to relate except through imaginary friend
C) Parental anxiety related to lack of understanding of childhood development
The parents need to understand that the child's behavior is not uncommon. Imaginary
friends are common in the preschool-age child. The child's behavior is not abnormal.
The child does not have a deep-set psychological need. The child is not at risk for social
isolation.
The nurse is observing the behavior of a preschool-age child and becomes concerned.
Which observation suggests that the child's thinking is inconsistent with normal
preschooler growth and development?
A) Refusing to play with "real" children
B) Refusing to go to bed without the friend
C) Insisting that an imaginary friend have dinner with the family
D) Insisting that an imaginary friend watch television with the child
A) Refusing to play with "real" children
Many preschoolers have an imaginary friend who plays with them. Imaginary friends are
a normal, creative part of the preschool years and can be invented by children who are
surrounded by real playmates as well as by those who have few friends. As long as the
child has exposure to real playmates and imaginary, do not take center stage in the
child's life or prevent them from socializing with other children; the imaginary friend
should not pose a problem. Refusing to go to bed without the friend, having the friend
eat dinner with the family, and watching television with the imaginary friend are all
acceptable behaviors by the preschool-age child.
During an assessment, a preschool-age child tells the nurse about having 12 siblings.
The nurse is aware that the child has two older brothers. What should the nurse
respond to this child?
A)"I guess you don't know much about counting yet."
B) "Don't lie to me. That's never a nice thing to do to someone."
C) "Does it make you feel more important when you add on brothers?"
D) "That is a good pretend answer but tell me the names of the brothers you really
have."
D) "That is a good pretend answer but tell me the names of the brothers you really
have."
Stretching stories to make them seem more interesting is a phenomenon frequently
encountered in preschoolers. This kind of storytelling should not be encouraged. The
child should be helped to separate fact from fiction. The nurse should ask the child to
say the names of the brothers the child really has. The nurse should not insult the
child's counting ability. The nurse should not accuse the child of lying or making the
child seem more important by having more brothers.
A community health center is planning a seminar about the 2020 National Health Goals
for preschool-age children. Which topics should be included in this seminar to address
safety? (Select all that apply.)
A) Protection against secondhand smoke
B) Providing helmets before riding a bicycle
C) Using appropriate restraints in motor vehicles
D) Removing houseplants from easy to reach areas
E) Posting the telephone number of the poison control agency
A) Protection against secondhand smoke
B) Providing helmets before riding a bicycle
C) Using appropriate restraints in motor vehicles
The 2020 National Health Goals for preschool-age children focus on safety and include
protecting preschoolers against secondhand smoke, using recommended automobile
restraints, and fitting children with helmets before beginning bicycle riding. Removing
houseplants and posting the telephone number of the poison control agency would be
appropriate for families with toddlers.
The mother of a preschool-age child is pregnant and wants to enroll the child in a child
care program. When should the nurse suggest that the child be enrolled in this
program?
A) By 4 years of age regardless of the pregnancy
B) Now after explaining that the new sibling will take up the mother's time
C) Three months before the baby is born, after the mother stresses that he is growing
up
D) Immediately after the baby is born so that the child will feel less jealous and more
secure
C) Three months before the baby is born, after the mother stresses that he is growing
up
If children are to start preschool or child care, it's best if they can do so either before the
new baby is born or 2 or 3 months afterward. That way, children can perceive starting
school as a result of maturity and not of being pushed out of the house by the new child.
There is no time limit about when a child should start preschool. The mother should not
explain to the child that the new baby will be taking up all of the mother's time.
00:02
01:01
The parents of a preschool-age child are investigating child care centers to enroll the
child. What should the nurse review with the parents prior to them making a decision?
(Select all that apply.)
A) Ask about the child-staff ratio.
B) Ask about the center's payment plan.
C) Find out if parents can visit at any time.
D) Find out how long the center has been in operation.
E) Ask about the center's licenses and compliance with regulations.
A) Ask about the child-staff ratio.
C) Find out if parents can visit at any time.
D) Find out how long the center has been in operation.
E) Ask about the center's licenses and compliance with regulations.
When investigating child care centers, the nurse should counsel the parents to find out
about the child-staff ratio, parental visiting hours, the time the center has been in
operation, and compliance with licenses and regulations. The payment plan might be
important to the parents; however, it should not be the sole factor in making a decision
about a child care center.
The nurse instructs a mother on actions to prevent sibling rivalry between a
preschool-age child and a newborn. Which observation indicates that instruction has
been effective?
A) Mother sleeps while the newborn is sleeping.
B) Mother asks if the preschool-age child likes the new baby.
C) Mother sets aside afternoon time for the preschool-age child while the baby naps.
D) Mother suggests family not bring gifts to the preschool-age child until behavior
changes
C) Mother sets aside afternoon time for the preschool-age child while the baby naps.
To help reduce sibling rivalry, the mother should set aside afternoon time for the
preschool-age child while the baby naps. Sleeping when the baby sleep, asking if the
preschool-age child likes the baby, and limiting gifts to the preschool-age child until
behavior changes will promote sibling rivalry.
The parents of a preschool-age child want to begin preparing the child to attend school.
What should the nurse suggest the parents discuss with the child to help with this
preparation?
A) Point out how to go to school.
B) Talk about school as an enjoyable experience.
C) Warn about how many rules there will be in school.
D) Encourage working on projects lying on the floor so school tables will be appreciated.
B) Talk about school as an enjoyable experience.
If school is discussed as something to look forward to, as an adventure that will be
satisfying and rewarding, a child comes to look forward to it as a positive experience.
Pointing out how to get home from school might be more important than how to get to
school. Warning about rules and expecting to work on the floor may cause the child to
view school as punishment.
https://quizlet.com/388972626/chapter-32-the-toddler-and-family-maternal-child-nursing-c
are-flash-cards/
SCHOOL-AGE CHILD
1. While planning care for a 7-year-old patient, the nurse reminds the parents that
children at this age are experiencing the "eraser" year. What does this mean?
A) The child wants to perform well.
B) The child believes in magical thinking.
C) The child is learning to write during this year.
D) The child tends to "erase" misdeeds or lie excessively.
Ans: A
Feedback:
Seven-year-olds concentrate on fine motor skills, and this year has been called the
"eraser" year because children are never quite content with what they have done. They
set too high a standard for themselves and then have difficulty performing at that level.
Toddlers believe in magical thinking. The child has already learned how to write. The
eraser year does not mean that the child is erasing misdeeds or lying.
2. The school nurse is reviewing content to include in an assembly planned for
school-age children that focuses on the 2020 National Health Goals for safety. What
should the school nurse include in this presentation? (Select all that apply.)
A) Encourage the children to play outdoors and get exercise everyday.
B) Stress the need to sit in age-appropriate seats in cars and wear seatbelts.
C) Remind children how important it is to brush the teeth and see the dentist.
D) Explain how important it is for children to wear safety helmets when bicycling.
E) Offer suggestions to ensure an adequate intake of fruits and vegetables each day.
Ans: B, D
Feedback:
Nurses can help the nation achieve the 2020 National Health Goals by urging children
to follow safety rules for automobile and bicycle safety. Playing outdoors, getting
exercise, and having an adequate intake of fruits and vegetables would be appropriate
for nutritional goals. Brushing the teeth and seeing the dentist would be appropriate for
health promotion goals.
3. The nurse is caring for a 9-year-old patient in the hospital. Which project should the
nurse provide to help this child achieve the developmental task of industry?
A) Sew a purse that will take one afternoon.
B) Watch favorite programs on the television.
C) Design a puppet show that will take 2 weeks to plan.
D) Work on a scrapbook that will take 3 weeks to complete.
Ans: A
Feedback:
Hobbies and projects are best enjoyed if they are small and can be finished within a
short time. Most school-age children prefer putting together something fairly simple
rather than something that is more complicated because the complicated one will delay
the reward, and the child may become bored and never complete it. Watching television
does not help the child achieve the developmental task of industry.
4. While making a visit to the home of a family with a school-age child, the nurse
observes a hunting rifle leaning against the wall in the dining room. Which nursing
diagnosis should the nurse use to guide interventions for the family at this time?
A) Anxiety
B) Risk for injury
C) Health-seeking behaviors
D) Readiness for enhanced parenting
Ans: B
Feedback:
The nursing diagnosis appropriate for this situation is risk for injury because the firearm
is in the dining room. The parents need instruction about safety precautions with
firearms and school-age children. There is no evidence of anxiety. The parents are not
asking for health-related information. The parents are not demonstrating readiness to
learn more about parenting.
5. When planning activities for school-age children, the nurse includes games that
include competition. At which age are these kinds of games the most preferred by
children?
A) 7 years old
B) 8 years old
C) 10 years old
D) 12 years old
Ans: C
Feedback:
During the 10th year, children become very interested in rules and fairness. Before this
time, they gave younger children breaks in games, allowing extra turns or hints. Now,
they strictly enforce rules. At age 7 years, imaginative play decreases and more props
are used. Children who are 8 years old like table games but avoid competitive ones
because they hate to lose. Twelve-year-olds enjoy all types of activities that may or may
not include competition.
6. Why should the nurse carry information about the Boy Scouts when visiting families
with male school-age children?
A) No girls are included in the organization.
B) Hiking is a favorite school-age activity.
C) Merit badges are rewarded for completing small tasks.
D) It strengthens relationships with fathers who participate in Boy Scouts.
Ans: C
Feedback:
Merit badge systems such as the Boy Scouts are geared to the needs of school-age
children, offering small but frequent rewards. This action strengthens the developmental
task of industry. The Boy Scouts is not attractive because the lack of girls, participating
in hiking, or strengthening relationships with fathers.
7. The nurse knows that being able to tell time helps a child become more independent.
At which age should the nurse expect a school-age child to begin to tell time?
A) 6 years old
B) 7 years old
C) 8 years old
D) 9 years old
Ans: B
Feedback:
Most 7-year-olds can tell the time in hours, but they may have trouble with concepts
such as "half past" and "quarter to," especially with the prevalence of digital clocks.
Six-year-olds still define objects by use. Eight- and nine-year-olds have moved passed
telling time and are interested in mastering other things.
8. While straightening the top drawer of a 10-year-old patient the nurse finds 48 packets
of sugar. What should the nurse do at this time?
A) Advise the mother to have the child tested for diabetes.
B) Throw out the sugar because this will promote dental caries.
C) Place the sugar packets in the drawer as they were found.
D) Ask the mother if the child has a history of craving sweets.
Ans: C
Feedback:
Ten-year-olds like having their own bedroom or at least their own dresser, where they
can store a collection and know it is free from parents' or siblings' eyes. One of the best
gifts for a 10-year-old is a box which locks. The nurse found the 10-year-old child's
collection and needs to return it where it was found. The child does not have diabetes.
The nurse should not throw out the child's collection. The mother does not need to be
asked about the child's craving sweets.
9. The nurse is talking with a mother who is concerned that a school-age child is
experiencing stress and has been biting the fingernails since beginning the first grade.
What should the nurse advise the mother to do about this problem?
A) Encourage the child to drink more milk for stronger nails.
B) Allow the child to choose a reward for not biting the nails.
C) Distract the child by teaching a new skill such as whistling.
D) Allow some time every day for the child to talk about new experiences.
Ans: D
Feedback:
Many first-graders are capable of mature action at school but appear less mature when
they return home. They may bite their fingernails. Scolding, nagging, threatening, or
punishing does not stop nail biting and may make the problem worse. This behavior will
stop when the underlying stress is discovered and alleviated. The mother should be
encouraged to spend some time with a child after school or in the evening so the child
continues to feel secured in the family and does not feel pushed out by being sent to
school. Drinking milk will not help alleviate the child's stress. Using rewards or teaching
new skills will not relieve the child's stress.
10. The nurse observes a school-age child categorize specific desk and clothing items
in his hospital room. What cognitive behavior has this child mastered?
A) Decentering
B) Conservation
C) Class inclusion
D) Accommodation
Ans: C
Feedback:
Class inclusion is the ability to understand that objects can belong to more than one
classification. A school-age child can categorize objects in many ways. Decentering is
the ability to project oneself into another person's situation. Accommodation is the ability
to adapt thought processes to fit what is perceived. Conservation is the ability to
appreciate that a change in shape does not mean a change in size.
11. A mother is concerned that a 7-year-old child has taken money from a sibling's
dresser several times. What should the nurse advise the mother about this behavior?
A) The child needs to be reminded of property rights.
B) Stealing is unusual for a 7-year-old and needs to be investigated.
C) The mother should purchase a bank for the other child that cannot be opened.
D) The mother should talk to the child's teacher about putting less pressure on the child.
Ans: A
Feedback:
Early childhood stealing is best handled without a great deal of emotion. A parent
should tell the child the money is missing. The importance of property rights should be
reviewed: The sibling's money is his, the child's money is the child's, and they are not
interchangeable. Stealing is not unusual for a 7-year-old child. The mother does not
need to buy the other child a bank. The behavior does not necessarily occur because of
school-related stress.
12. A 9-year-old girl tells the nurse about belonging to a spite club. How does belonging
to this group support the child's development?
A) Fulfills peer group needs
B) Teaches the child leadership skills
C) Helps the child develop autonomy
D) Encourages the child to learn rules
Ans: A
Feedback:
Nine-year-olds take the values of their peer group very seriously. This is typically the
friend or club age because children form groups, usually "spite clubs." This type of club
does not teach the child leadership skills, develop autonomy, or to learn rules.
13. The mother of a school-age child is distraught because the child has been
diagnosed with obesity. What actions should the nurse suggest to the mother to help the
child with this problem? (Select all that apply.)
A) Explain that obesity will lead to an early death.
B) Maintain a balanced eating approach in the home.
C) Purchase books explaining the latest ways to lose weight.
D) Seek out a preteen weight loss group for the child to participate.
E) Encourage increased activity such as walking the dog after school.
Ans: B, D, E
Feedback:
Strategies to help the school-age child with obesity include maintaining a healthy eating
approach in the home, seeking a weight loss group with other preteens for the child to
attend, and encouraging increased activity. Explaining that obesity will lead to an early
death could cause the child to become obsessed with dieting and create an eating
disorder. The child should not be encouraged to use fad diets to lose weight.
14. The nurse has been caring for a family with a school-age child who has school
phobia. Which observation indicates that interventions have been successful?
A) The child stays home from school.
B) The child attends school every day.
C) The child decides daily about attending school.
D) The child's teacher is asked if attending school is a requirement.
Ans: B
Feedback:
Once it has been established that a child is free of any illness and the resistance stems
from separation anxiety or phobia, the child should be made to attend school.
Reinforcement by parents to go to school this way helps to prevent problems such as
school failure, peer ridicule, or a pattern of avoiding difficulties. Some children may
benefit from a gradual program of school involvement. Managing school refusal requires
coordination among the school, school nurse, and health care provider who identifies
the problem. The child should not be permitted to decide not to go to school. Attending
school is a requirement, and the teacher does not need to be asked this question.
15. A 10-year-old child spends 2 hours alone every afternoon before the parents arrive
home from work. Which safety measure should the nurse suggest the parents teach the
child?
A) Preparing a no-cook snack after school
B) Lighting candles in case there is a power failure
C) Wearing the house key prominently around the neck
D) Telling people at school about being home alone or added safety
Ans: A
Feedback:
Parents should plan after-school snacks for the child that does not require cooking to
prevent burns. Lighting candles could be a fire hazard if they are left unattended.
Wearing the house key around the neck could indicate that the child will be home alone.
Telling people at school about being home alone could encourage a break in or other
action against the child.
16. A mother is concerned that a school-age child will pick up the habit of smoking
because so many children in the school smoke. What should the nurse instruct the
mother about this behavior?
A) Be a role model and do not smoke.
B) Remind the child that smoking costs money.
C) Discuss other tobacco choices that can be used instead.
D) Explain that the child can experiment with smoking when older.
Ans: A
Feedback:
To discourage use of tobacco by school-age children, parents need to be role models of
excellent nonsmoking health behavior in hopes children will follow their good example.
Explaining that smoking costs money might not make an impact on a school-age child's
decision to start smoking. Discussing other tobacco choices is inappropriate because
smokeless tobacco also has associated health risks. The child should be encouraged to
refrain from smoking throughout life.
When obtaining a health history from a patient, the nurse should....(Select all that
apply.)
a) Chief complaint
b) History of past illnesses
c.) The patient's pet names
d) Developmental history
e) Parents' job status
ABD
a) Chief complaint
b) History of past illnesses.
d) Developmental history
The nurse is doing her initial assessment on an adolescent. What is the nurse's
determination when using percussion? Select all that apply.
a) Firmness
b) Location
c) Size
d) Density of organs
e) Masses
f) Tenderness
BCDE
b) Location
c) Size
d) Density of organs
e) Masses
When asking about past health history, you must ask about.....Select all that apply.
a) Child's diet and allergies
b) Child's daily routine
c) Prior history of illnesses, accidents or injuries
d) Any meds the child is currently taking
e) Child's immunization status
ACDE
a) Child's diet and allergies
c) Prior history of illnesses, accidents or injuries
d) Any meds the child is currently taking
e) Child's immunization status
A nurse is assessing the bonding of the father with his newborn baby. Which of the
following actions by the father would be of concern to the nurse?
a) He holds the baby in the enface position.
b) He calls the baby by a full name rather than a nickname.
c) He tells the mother to pick up the crying baby.
d) He falls asleep in the chair with the baby on his chest
C
c) He tells the mother to pick up the crying baby.
What failed test would indicate that a three-week infant may have blindness?
a) PERRLA exam
b) Tonometry test
c) Visual field test
d) A routine eye exam
A
a) PERRLA exam
When reviewing the systems for the physical assessment of the child, a nurse would
note that weight loss in the child would fall under which system?
a) Gastrointestinal system
b) Mouth, teeth, and throat
c) Growth and development
d) Musculoskeletal system
C
c) Growth and development
Which of the following is the best method for performing a physical examination on a
toddler?
a) From head to toe
b) Distally to proximally
c) From abdomen to toes, to the head
d) From least to most intrusive
D
d) From least to most intrusive
Which of the following should alert the nurse that there is concern among the dynamic
of the family?
a) The parent does not make eye contact with an infant.
b) The parents increase the school age child's sense of self-worth.
c) The parents ignore the two-year-old's tantrum so that neither positive nor negative
reinforcement is established.
d) The parent anticipates and responds to the infant's need.
A
a) The parent does not make eye contact with an infant.
Which of these children is most at risk for heart alterations?
a) A child diagnosed with rubella
b) A child with leukemia who recently a bone marrow transplant
c) A toddler with a heart rate of 115
d) An 8-year old with pneumonia
B
b) A child with leukemia who recently a bone marrow transplant
A female child, age 6, is brought to the health clinic for a routine check-up. To assess
the child's vision, the nurse should ask...
a) "Do you have any problems seeing different colors?"
b) "Do you have trouble seeing at night?"
c) "Do you have problems with glare?"
d) "How are you doing at school?"
D
d) "How are you doing at school?"