Test Bank For Maternal-Child Nursing 6th Edition By Emily Slone McKinney
4. A preschool-age child is being admitted for some diagnostic tests
and possible surgery. The nurse planning care should use which
phrases when explaining procedures to the child? (Select all that
apply.)
a. Fluids will be given through tubing connected to a tiny tube
inserted into your arm.
b. After surgery we will be doing dressing changes.
c. You will get a shot before surgery.
d. The doctor will give you medicine that will help you go into a deep sleep.
e. We will take you to surgery on a bed on wheels.
ANS: A, D, E
A preschool child needs simple concrete explanations that cannot be misinterpreted. An IV
should be explained as fluids going into a tube connected to a small tube in your hand;
anesthesia can be explained as a medicine that will help you go into a deep sleep (put to sleep
should be avoided); and a stretcher can be described as riding on a bed with wheels. The term
―dressing changesǁ is ambiguous and will not be understood by a preschooler. The term ―get a
shotǁ should not be used. A preschooler or young child is likely to misinterpret this
information.
PTS:1 DIF:
Cognitive Level: Understanding
OBJ:Integrated Process: Communication and Documentation
MSC:Client Needs: Psychosocial Integrity
Chapter 05: Health Promotion for the Developing Child
McKinney: Evolve Resources for Maternal-Child Nursing, 6th Edition
MULTIPLE CHOICE
1. Which statement best describes development in infants and children?
a. Development, a predictable and orderly process, occurs at varying rates within
normal limits.
b. Development is primarily related to the growth in the number and size of cells.
c. Development occurs in a proximodistal direction with fine muscle development
occurring first.
d. Development is more easily and accurately measured than growth.
ANS: A
Development, a continuous and orderly process, provides the basis for increases in the child‘s
function and complexity of behavior. The increases in rate of function and complexity can
vary normally within limits for each child. An increase in the number and size of cells is a
definition for growth. Development proceeds in a proximodistal direction with fine muscle
organization occurring as a result of large muscle organization. Development is a more
complex process that is affected by many factors; therefore, it is less easily and accurately
measured. Growth is a predictable process with standard measurement methods.
PTS:1 DIF:
Cognitive Level: Remembering
OBJ:Nursing Process: Assessment
MSC:Client Needs: Health Promotion and Maintenance
2. Frequent developmental assessments are important for which reason?
a. Stable developmental periods during infancy provide an opportunity to identify
any delays or deficits.
b. Infants need stimulation specific to the stage of development.
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Test Bank For Maternal-Child Nursing 6th Edition By Emily Slone McKinney
c. Critical periods of development occur during childhood.
d. Child development is unpredictable and needs monitoring.
ANS: C
Critical periods are blocks of time during which children are ready to master specific
developmental tasks. The earlier those delays in development are discovered and intervention
initiated, the less dramatic their effect will be. Infancy is a dynamic time of development that
requires frequent evaluations to assess appropriate developmental progress. Infants in a
nurturing environment will develop appropriately and will not necessarily need stimulation
specific to their developmental stage. Normal growth and development is orderly and
proceeds in a predictable pattern based on each individual‘s abilities and potentials.
PTS:1 DIF:
Cognitive Level: Understanding
OBJ:Nursing Process: Assessment
MSC:Client Needs: Health Promotion and Maintenance
3. The nurse is assessing an infant‘s growth and development. The parents want education on
how to stimulate this process. What action suggested by the nurse is inconsistent with
knowledge of this topic?
a. Have the family draw a three-generation family pedigree.
b. Show the family how to coo and babble with their child.
c. Encourage the parents to buy interactive toys for the child.
d. Involve the child in activities that are outside the home.
ANS: A
A family pedigree can help show relationships and health care problems but will not stimulate
growth and development. Activities that are stimulating for a child include the consistent use
of language by the parents, allowing play time with interactive toys (toys that make noises or
do something in response to the baby‘s actions), and exposing the child to new sights and
sounds.
PTS:1 DIF:
Cognitive Level: Applying
OBJ:Integrated Process: Teaching-Learning
MSC:Client Needs: Health Promotion and Maintenance
4. According to Piaget‘s theory, the period of cognitive development in which the child is able to
distinguish between concepts related to fact and fantasy, such as human beings are incapable
of flying like birds, is the
period of cognitive development.
a. sensorimotor
b. formal operations
c. concrete operations
d. preoperational
ANS: C
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Test Bank For Maternal-Child Nursing 6th Edition By Emily Slone McKinney
Concrete operations is the period of cognitive development in which children‘s thinking is
shifted from egocentric to being able to see another‘s point of view. They develop the ability
to distinguish fact from fantasy. The sensorimotor stage occurs in infancy and is a period of
reflexive behavior. During this period, the infant‘s world becomes more permanent and
organized. The stage ends with the infant demonstrating some evidence of reasoning. Formal
operations is a period in development in which new ideas are created through previous
thoughts. Analytic reason and abstract thought emerge in this period. The preoperational stage
is a period of egocentrism in which the child‘s judgments are illogical and dominated by
magical thinking and animism.
PTS:1 DIF:
Cognitive Level: Remembering
OBJ:Nursing Process: Assessment
MSC:Client Needs: Health Promotion and Maintenance
5. A nurse wants to assess a chronically ill child‘s feelings regarding a lengthy hospitalization
and treatments. What action by the nurse is best?
a. Ask direct questions of the child as to feelings.
b. Watch the child play on several occasions.
c. Discuss the situation with the parents.
d. Refer the child to the child life specialist for assessment.
ANS: B
Play for all children is an activity woven with meaning and purpose. For chronically ill
children, play can indicate their state of wellness and response to treatment. It is a way to
express joy, fear, anxiety, and disappointments. The nurse can best decipher the child‘s
emotional state by observing this activity. Children often are threatened by direct questions,
especially if the questioner is not well known to the child. The nurse may want to discuss the
situation with the parents or enlist the help of the child life specialist, but these will not give
the nurse the rich data that can be obtained through watching the child play.
PTS:1 DIF:
Cognitive Level: Applying
OBJ:Nursing Process: Assessment
MSC:Client Needs: Health Promotion and Maintenance
6. A nurse uses Erikson‘s theory to guide nursing practice. What action by a hospitalized
4-year-old child would the nurse evaluate as developmentally appropriate?
a. Dressed and fed by the parents
b. Independently ask for play materials or other personal needs
c. Verbalizes an understanding of the reason for the hospitalization
d. Asks for a parent stay in the room at all times
ANS: B
Erikson identifies initiative as a developmental task for the preschool child. Initiating play
activities and asking for play materials or assistance with personal needs demonstrates
developmental appropriateness. Parents need to foster appropriate developmental behavior in
the 4-year-old child. Dressing and feeding the child do not encourage independent behavior. A
4-year-old child cannot be expected to cognitively understand the reason for hospitalization.
Expecting the child to verbalize an understanding for hospitalization is an inappropriate
outcome. Parents staying with the child throughout a hospitalization is not a developmental
outcome. Although children benefit from parental involvement, parents may not have the
support structure to stay in the room with the child at all times.
PTS:1 DIF:
Cognitive Level: Evaluating OBJ:Nursing Process: Evaluation
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MSC:Client Needs: Health Promotion and Maintenance
7. The parents of a preschool-aged child are in the clinic and report the child is seen playing with
the genitals frequently. What response by the nurse is best?
a. Reassure parents this is normal at this age.
b. Teach parents about behavior modification.
c. Refer parents and child to a psychologist.
d. Ask the provider to speak to the parents.
ANS: A
Preschool children are in the Phallic or Oedipal/Electra Stage of Freud‘s theory during which
the genitals become the focus of curiosity and interest. The nurse should explain that this
behavior is normal at this stage. Teaching about disciplinary techniques and referrals to
psychotherapy are inappropriate. The nurse may well want the provider to speak to the
parents, but the nurse is responsible for patient/parent teaching and should provide education
him- or herself.
PTS:1 DIF:
Cognitive Level: Applying
OBJ:Integrated Process: Teaching-Learning
MSC:Client Needs: Health Promotion and Maintenance
8. A nurse is teaching parents to avoid environmental injury to their 2-year-old child. What
information does the nurse include in teaching?
a. Avoiding sun exposure, secondhand smoke, and lead
b. Living in a middle-class neighborhood
c. Avoiding smoking and alcohol intake during pregnancy
d. Limiting breastfeeding to avoid toxins being passed through breast milk
ANS: A
Lead can be present in the home and in toys made overseas. Environmental injury can also be
the result of mercury, pesticides (flea and tick collars), radon, and exposure to the sun and
secondhand smoke. It is important for the nurse to provide health teaching related to these
factors. The nurse is unable to influence socioeconomic status, and the family may not want or
be able to move. It is too late for the nurse to instruct the mother regarding smoking or alcohol
intake during pregnancy. This should have been included in prenatal teaching. It is unlikely
that a 2-year-old child will still be breastfeeding.
PTS:1 DIF:
Cognitive Level: Understanding
OBJ:Integrated Process: Teaching-Learning
MSC:Client Needs: Health Promotion and Maintenance
9. When counseling parents and children about the importance of increased physical activity, the
nurse will emphasize which of the following?
a. Anaerobic exercise should comprise a major component of the child‘s daily
exercise.
b. All children should be physically active for at least 2 hours per day.
c. It is not necessary to participate in physical education classes at school if a student
is taking part in other activities.
d. Make exercise a fun and habitual activity.
ANS: D
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Test Bank For Maternal-Child Nursing 6th Edition By Emily Slone McKinney
It is important to make exercise a fun and habitual activity. Encourage parents to investigate
their community‘s different activity programs. This includes recreation centers, parks, and the
YMCA. Aerobic exercise should comprise a major component of children‘s daily exercise;
however, physical activity should also include muscle- and bone-strengthening activities.
Children and adolescents should be physically active for at least 1 hour daily. Encourage all
students to participate fully in any physical education classes.
PTS:1 DIF:
Cognitive Level: Understanding
OBJ:Integrated Process: Teaching-Learning
MSC:Client Needs: Health Promotion and Maintenance
10. A student nurse is preparing to administer an Hib vaccination to an infant. What action by the
student requires the registered nurse to intervene?
a. Gives the vaccine information statement prior to administering the vaccine
b. Wipes the dorsal gluteal area with alcohol prior to injection
c. Obtains written informed consent before giving the vaccine
d. Assesses the family‘s beliefs and values about vaccinations
ANS: B
The anterolateral thigh is the preferred site for intramuscular administration of vaccines for
infants. When the student prepares the wrong site, the registered nurse should intervene.
Federal law requires parents be given vaccine information statements and sign informed
consent prior to the nurse‘s administering vaccinations. The nurse should also assess the
family‘s beliefs and values related to vaccination, which can help dispel myths and guide
teaching.
PTS:1 DIF:
Cognitive Level: Applying
OBJ:Nursing Process: Implementation
MSC:Client Needs: Safe and Effective Care Environment
11. A nurse is planning to teach about injury prevention to a group of parents. What action by the
nurse would best ensure a successful event?
a. Have handouts listing community resources.
b. Provide free safety gear like bike helmets.
c. Group parents by child‘s developmental stage.
d. Present the material in an interactive way.
ANS: C
When providing anticipatory guidance to prevent injury, the most important thing for the
nurse to know and understand is developmental levels of the children involved. Grouping
parents by their child‘s developmental level allows the nurse to know this information about
the group and to provide teaching specific to the group. The other options will help but are not
as important as tailoring teaching to the specific needs of the children.
PTS:1 DIF:
Cognitive Level: Applying
OBJ:Integrated Process: Teaching-Learning
MSC:Client Needs: Health Promotion and Maintenance
12. A nurse is assessing a 1-year-old‘s food intake over the past 3 days. What information from
the parent leads the nurse to provide education on nutrition?
a. Child drinks 2 cups of 1% milk each day.
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Test Bank For Maternal-Child Nursing 6th Edition By Emily Slone McKinney
b. Child loves to snack on fruit throughout the day.
c. Child gets one 4-ounce cup of juice with breakfast.
d. Parent allows child to regulate own portions at meals.
ANS: A
A child this age should not be drinking low-fat milk. Snacking on fruit, 4 ounces of juice, and
not forcing the child to eat everything on the plate are appropriate activity and do not require
education.
PTS:1 DIF:
Cognitive Level: Understanding
OBJ:Integrated Process: Teaching-Learning
MSC:Client Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. The nurse preparing to administer the Denver Developmental Screening Test II (DDST-II)
should understand that it assesses which functional areas? (Select all that apply.)
a. Personal-functional
b. Fine motor
c. Intelligence
d. Language
e. Gross motor
ANS: A, B, D, E
The four functional areas assessed by this tool are personal-functional, fine motor, language,
and gross motor. It is not an intelligence test.
PTS:1 DIF:
Cognitive Level: Remembering
OBJ:Nursing Process: Assessment
MSC:Client Needs: Health Promotion and Maintenance
2. An immunocompromised child is in the clinic for immunizations. Which vaccine
prescriptions should the nurse question? (Select all that apply.)
a. DTaP
b. HepA
c. IPV
d. Varicella
e. MMR
ANS: D, E
Children who are immunologically compromised should not receive live viral vaccines.
Varicella is a live vaccine and should not be given except in special circumstances. MMR is a
live vaccine and should not be given to immunologically compromised children. DTaP,
HepA, and IPV can be given safely.
PTS:1 DIF:
Cognitive Level: Remembering
MSC:Client Needs: Physiologic Integrity
OBJ:Nursing Process: Planning
3. A preschool aged child is in the clinic for a well-child checkup. Which statement identifies an
appropriate level of language development in this child? (Select all that apply.)
a. Vocabulary of 300 words
b. Relates elaborate tales
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Test Bank For Maternal-Child Nursing 6th Edition By Emily Slone McKinney
c. Uses correct grammar in sentences
d. Able to pronounce consonants clearly
e. Expresses abstract thought
ANS: B, C
The 4-year-old child is able to use correct grammar in sentence structure and can tell elaborate
tales and stories. A vocabulary of 300 words is appropriate for a 2-year-old. The 4-year-old
child typically has difficulty in pronouncing consonants. The use of language to express
abstract thought is developmentally appropriate for the adolescent.
PTS:1 DIF:
Cognitive Level: Remembering
OBJ:Nursing Process: Assessment
MSC:Client Needs: Health Promotion and Maintenance
4. A 2-month-old child has not had any immunizations. Which ones should the nurse prepare to
give? (Select all that apply.)
a. Hib
b. HepB
c. MCV
d. Varicella
e. HPV
ANS: A, B, C, D
Hib, HepB, MCV, and varicella are all appropriate vaccinations for this child. HPV is for
adolescents.
PTS:1 DIF:
Cognitive Level: Remembering
OBJ:Nursing Process: Implementation
MSC:Client Needs: Health Promotion and Maintenance
Chapter 06: Health Promotion for the Infant
McKinney: Evolve Resources for Maternal-Child Nursing, 6th Edition
MULTIPLE CHOICE
1. Approximately how much would a newborn who weighed 7 pounds 6 ounces at birth weigh at
1 year of age?
a. 14 3/4 lb
b. 22 1/8 lb
c. 29 1/2 lb
d. Unable to estimate weigh at 1 year
ANS: B
An infant triples birth weight by 1 year of age. The other calculations are incorrect.
PTS:1 DIF:
Cognitive Level: Applying
OBJ:Nursing Process: Assessment
MSC:Client Needs: Health Promotion and Maintenance
2. Which statement made by a mother is consistent with a developmental delay?
a. ―I notice my 9-month-old infant responds consistently to his name.ǁ
b. ―My 12-month-old child does not get herself to a sitting position or pull to stand.ǁ
c. ―I am so happy when my 1 1/2-month-old infant smiles at me.ǁ
d. ―My 5-month-old infant is not rolling over in both directions yet.ǁ
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ANS: B
Critical developmental milestones for gross motor development in a 12-month-old include
standing briefly without support, getting to a sitting position, and pulling to stand. If a
12-month-old child does not perform these activities, it may be indicative of a developmental
delay. An infant who responds to his name at 9 months of age is demonstrating abilities to
both hear and interpret sound. A social smile is present by 2 months of age. Rolling over in
both directions is not a critical milestone for gross motor development until the child reaches
6 months of age.
PTS:1 DIF:
Cognitive Level: Understanding
OBJ:Nursing Process: Assessment
MSC:Client Needs: Health Promotion and Maintenance
3. The nurse is performing a routine assessment on a 14-month-old infant and notes that the
anterior fontanel is closed. This should be interpreted as a(n)
a. normal finding—nurse should document finding in chart.
b. questionable finding—infant should be rechecked in 1 month.
c. abnormal finding—indicates need for immediate referral to practitioner.
d. abnormal finding—indicates need for developmental assessment.
ANS: A
This is a normal finding. The anterior fontanel closes between ages 12 and 18 months. The
posterior fontanel closes between 2 and 3 months of age. There is no need for a recheck, a
referral, or a developmental assessment.
PTS:1 DIF:
Cognitive Level: Analyzing
OBJ:Nursing Process: Assessment
MSC:Client Needs: Health Promotion and Maintenance
4. The nurse advises the mother of a 3-month-old exclusively breastfed infant to
a. start giving the infant a vitamin D supplement.
b. start using an infant feeder and add rice cereal to the formula.
c. start feeding the infant rice cereal with a spoon at the evening feeding.
d. continue breastfeeding without any supplements.
ANS: A
Breast milk does not provide an adequate amount of dietary vitamin D. Infants who are
exclusively breastfed need vitamin D supplements to prevent rickets. An infant feeder is an
inappropriate method of providing the infant with caloric intake. Solid foods are not
recommended for a 3-month-old infant. Rice cereal and other solid foods are contraindicated
in a 3-month-old infant. Solid feedings do not typically begin before 4 to 6 months of age.
PTS:1 DIF:
Cognitive Level: Understanding
OBJ:Integrated Process: Teaching-Learning
MSC:Client Needs: Health Promotion and Maintenance
5. The mother of a 9-month-old infant is concerned because the infant cries when approached by
an unknown shopper at the grocery store. What is the best response for the nurse to make to
the mother?
a. ―You could consider leaving the infant with other people so he can adjust.ǁ
b. ―You might consider taking her to the doctor because she may be ill.ǁ
c. ―Have you noticed whether the baby is teething?ǁ
d. ―This is a sign of stranger anxiety and demonstrates healthy attachment.ǁ
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ANS: D
An infant who manifests stranger anxiety is showing a normal sign of healthy attachment.
This behavior peaks at 7 to 9 months and is developmentally appropriate. The mother leaving
the child more often will not change this developmental response to new strangers. The child
does not need to see a doctor, and teething is unrelated.
PTS:1 DIF:
Cognitive Level: Understanding
OBJ:Integrated Process: Teaching-Learning
MSC:Client Needs: Health Promotion and Maintenance
6. A mother of a 2-month-old infant tells the nurse, ―My child doesn‘t sleep as much as his older
brother did at the same age.ǁ What is the best response for the nurse?
a. ―Have you tried to feed the baby more often or play more before bedtime?ǁ
b. ―Infant sleep patterns vary widely, some infants sleep only 2 to 3 hours at a time.ǁ
c. ―Keep a record of your baby‘s eating, waking, sleeping, and elimination patterns
and to come back to discuss them.ǁ
d. ―This infant is difficult. It is important for you to identify what is bothering the
baby.ǁ
ANS: B
Newborn infants may sleep as much as 17 to 20 hours per day. Sleep patterns vary widely,
with some infants sleeping only 2 to 3 hours at a time. Infants typically do not need more
caloric intake to improve sleep behaviors. Stimulating activities before bedtime may keep the
baby awake. There is no need for the mother to keep behavior records. Just because an infant
may not sleep as much as a sibling did does not justify labeling the child as being difficult.
Identifying an infant as difficult without identifying helpful actions is not a therapeutic
response for a parent concerned about sleep.
PTS:1 DIF:
Cognitive Level: Applying
OBJ:Nursing Process: Implementation
MSC:Client Needs: Health Promotion and Maintenance
7. The mother of a 10-month-old infant tells the nurse that her infant ―really likes cow‘s milk.ǁ
What is the nurse‘s best response to this mother?
a. ―Milk is a nutritious choice at this time.ǁ
b. ―Children should not get cow‘s milk until 1 year of age.ǁ
c. ―Limit cow‘s milk to one bedtime bottle.ǁ
d. ―Mix cereal with cow‘s milk and feed it in a bottle.ǁ
ANS: B
It is best to wait until the infant is at least 1 year old before giving him cow‘s milk because of
the risk of allergies and gastrointestinal problems, such as bleeding. Cow‘s milk protein
intolerance is the most common food allergy during infancy. Although milk is a good source
of calcium and protein for children after the first year of life, it is not the best source of
nutrients for children younger than 1 year old. Bedtime bottles of formula or milk are
contraindicated because of their high sugar content, which leads to dental decay in primary
teeth. Food and milk or formula should not be mixed in a bottle.
PTS:1 DIF:
Cognitive Level: Applying
OBJ:Integrated Process: Teaching-Learning
MSC:Client Needs: Physiologic Integrity
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Test Bank For Maternal-Child Nursing 6th Edition By Emily Slone McKinney
8. A nurse is modeling play time with a 6-month-old infant. Which activity is appropriate?
a. Pat-a-cake, peek-a-boo
b. Ball rolling, hide-and-seek game
c. Bright rattles and tactile toys
d. Push-and-pull toys
ANS: A
Six-month-old children enjoy playing pat-a-cake and peek-a-boo. Nine-month-old infants
enjoy rolling a ball and playing hide-and-seek games. Four-month-old infants enjoy bright
rattles and tactile toys. Twelve-month-old infants enjoy playing with push-and-pull toys.
PTS:1 DIF:
Cognitive Level: Remembering
OBJ:Nursing Process: Implementation
MSC:Client Needs: Health Promotion and Maintenance
9. A nurse is teaching a parent group about dental hygiene for their babies. What information
does the nurse provide?
a. Babies don‘t need dental care until they are three.
b. Start brushing teeth when all of them have come in.
c. Children are ready for dental care when they can hold a toothbrush.
d. Start with the first tooth using a cotton swab and water to wipe the teeth.
ANS: D
An infant‘s teeth need to be cleaned as soon as they erupt. Cleaning the teeth with cotton
swabs or a face cloth is appropriate. Waiting until all the baby teeth are in is inappropriate and
prolongs cleaning until 2 years of age. Being able to hold a toothbrush is not necessary as the
parents should clean the teeth.
PTS:1 DIF:
Cognitive Level: Applying
OBJ:Integrated Process: Teaching-Learning
MSC:Client Needs: Physiologic Integrity
10. A nurse observes that a 3-month-old infant will hold a rattle if it is put in the hands, but the
baby will not voluntarily grasp it. What action by the nurse is most appropriate?
a. Provide anticipatory guidance.
b. Document the findings in the chart.
c. Refer the family to a neurologist.
d. Perform a developmental screening.
ANS: B
This child is displaying normal age-appropriate behavior. The nurse should document the
findings, but no other action is necessary. The nurse should always provide appropriate
anticipatory guidance, but this answer is too vague to be the best response.
PTS:1 DIF:
Cognitive Level: Applying
OBJ:Nursing Process: Implementation
MSC:Client Needs: Health Promotion and Maintenance
11. In terms of gross motor development, what would the nurse expect a 5-month-old infant to
do?
a.
b.
c.
d.
Roll from abdomen to back.
Roll from back to abdomen.
Sit erect without support.
Move from prone to sitting position.
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