PrepU exam one- peds
The nurse is assessing an adolescent's risk for harm from guns being present in the home. What question would be best to ask during the assessment?
"Are the guns in your home locked in a safe?
A parent calls the health care provider about the 7-year-old child's dental hygiene. The child has had three cavities. The parent does not know what to do and asks the nurse for guidance. How should the nurse respond?
"Are you able to supervise your child's brushing?"
The parents of a 5-year-old tell the student nurse, "Our daughter takes after her father's lack of athletic ability. We have worked with her but she can't seem to throw a ball at all when we are playing with her." Which responses by the student are not appropriate? Select all that apply. (ALL OPTIONS ARE CORRECT
"Athletic ability is often hereditary, so it is good you are aware of her lack of athleticism while she is young." (pick this one)
A nurse is caring for a 4-year-old child. The parents indicate that their child often reports that objects in the house are his friends. The parents are concerned because the child says that the grandfather clock in the hallway smiles and sings to him. Which response by the nurse is best?
"Attributing lifelike qualities to inanimate objects is quite normal at this age.
The nurse is talking with the parents of an 8-year-old child who has been cheating at school. Which comment by the nurse would be appropriate as a first step?
"Be sure the adults in the child's life, including you, as parents, demonstrate positive behavior."
A 16-year-old girl has arrived for her sports physical with a new piercing in her navel. Which response by the nurse is best?
"Be sure to clean the navel several times a day."
The mother of a 7-year-old girl is asking the nurse's advice about getting her daughter a 2-wheel bike. Which response by the nurse is most important?
"Be sure to get the proper size bike."
The nurse is assessing a newborn child. The mother asks why the feet are blue. What is the best response by the nurse?
"Blueness of hands and feet is a common finding in newborns. It is a result of their circulatory system switching from being in the womb to life outside the mom's body."
The parents of an 8-year-old boy report their son is being bullied and teased by a group of boys in the neighborhood. Which response by the nurse is best?
"Bullying can have lifelong effects on the self-esteem of a child."
The most important safety precaution for parents to teach preschoolers is:
Don't ride in care with strangers
The nurse is counseling an overweight, sedentary 15-year-old girl. The nurse is assisting her to make appropriate menu choices. Which statement indicates the adolescent understands how to make appropriate dietary selections?
"I need to eat plenty of fruit each day.
A nurse is explaining cognitive development in children to a client, with the help of Piaget's theory of cognitive development. What would be the best explanation by the nurse about the formal operations level of cognitive development?
After age 12 children can think in the abstract, including complex problem solving.
The parents of a 4-year-old child tell the school nurse that they are worried that their child will fall behind other children academically because they are not able to afford expensive toys like computer games and handheld electronic devices. Which are acceptable response(s) by the nurse? Select all that apply. (ALL ARE CORRECT)
"I understand how this can be frustrating, but rest assured this does not place your child at a disadvantage academically." (pick this one)
The mother of a 9-year-old female voices concern to the nurse about her daughter developing breasts "at such a young age." How should the nurse respond?
"I understand your concern, but girls typically enter puberty around the age of 9 or 10."
The mother of a 4-year-old reports using time-outs as a means for disciplining the child. Which statement by the mother would require the nurse to provide additional teaching?
"I usually have him in time-out for about 10 minutes."
The nurse is presenting information about school-aged children at a community event. Which statement from the group should the nurse prioritize to address with further teaching and more information?
Food is so expensive, we always make our children eat everything on their plates."
A mother is concerned because her 14-month-old son, who had a big appetite when breastfeeding a few months ago, seems uninterested in eating solid food. She still breastfeeds him daily but is thinking of weaning him soon. How should the nurse respond to this mother?
"It is normal for toddlers to lose their appetites; try starting him with just a tablespoonful of food on his plate
A mother is concerned because her 14-month-old son, who had a big appetite when breastfeeding a few months ago, seems uninterested in eating solid food. She still breastfeeds him daily but is thinking of weaning him soon. How should the nurse respond to this mother?
"It is normal for toddlers to lose their appetites; try starting him with just a tablespoonful of food on his plate.
The nurse is presenting nutritional information at a community health fair. Which suggestion should the nurse prioritize when illustrating proper nutrition for preschoolers?
Snacks throughout the day help the child meet nutritional requirements
A parent tells the nurse that the 6-year-old child has been biting his fingernails since beginning first grade. After analysis, the cause is determined to be increased stress. What advice would the nurse give the parent regarding this behavior?
Allow some time every day for the child to talk about new experiences
The student nurse is preparing a presentation on normal physical growth for toddlers. What information should the student include? Select all that apply. (ALL ARE CORRECT)
The average weight gain is 3 to 5 pounds per year. (PICK THIS)
A toddler's parent reports that their child will only eat peanut butter and jelly sandwiches for several days in a row. The child will then refuse to eat these sandwiches for several weeks. How should the nurse best document this behavior?
Food jag
The nurse is providing anticipatory guidance to the parent of a 2-month-old infant in relation to growth and development. Which statement from the parent demonstrates proper understanding?
"I can expect my infant to be able to raise the head up when on the stomach within the next month."
The nurse is teaching a group of novice nurses how to assess bowel sounds. Which statement will the nurse include in the education?
"You should auscultate all four quadrants for a full minute each."
What statement by the mother of a 20-month-old indicates a need for further teaching about nutrition?
"I give my daughter juice at breakfast and when she is thirsty during the day.
A 9-month-old has been brought to the clinic for a well-child visit. The mother reports her son was born 6 weeks prematurely. During the data collection, the child's mother reports her son seems to be a few months "behind" what she recalls from her older children. What is the best response by the nurse?
"Delays are normal when a child is premature."
The nurse is teaching a group of school-aged children about physical development. Which statement made by one of the children indicates the correct understanding of the teaching?
"Girls typically experience a rapid growth spurt before boys."
The nurse is caring for an 11-year-old girl. The girl's mother reports that the girl does not want to play team sports like soccer or volleyball anymore. Her daughter insists she does not enjoy them. The mother is concerned that her daughter will not get enough physical activity and asks the nurse for guidance. How should the nurse respond?
"Give her some options; it's important to find something she enjoys."
When questioning a 15-year-old about his health history, what would be an appropriate way for the nurse to ask about the child's drug history?
"Have you heard that some teens like to smoke? Have you tried this?
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.
The nurse is conducting a well-child exam of a 4-year-old boy. Which statement would alert the nurse that the child is at risk for iron deficiency?
"He loves milk and drinks it every time he is thirsty.
The nurse is measuring the head circumference of a 1-year-old infant during a well-child visit. The parent asks the nurse why this assessment is being performed. Which response will the nurse provide to the parent?
"Head circumference is typically assessed until age 2 or 3 to help determine if growth is appropriate."
The nurse has completed an educational program on normal growth and development in children. Which statement by a participant would indicate a need for further education?
"I am so glad I can get rid of all of those bath toys because they take up so much room."
The nurse is teaching a group of school-age children about physical development. Which statement made by one of the children indicates the correct understanding of the teaching?
"I will grow an average of 2.5 in (6.5 cm) per year."
The nurse is educating the parents of a newborn prior to discharge home. The parents demonstrate teaching was successful when making which statement(s)? Select all that apply (ALL ARE CORRECT)
"I will not be concerned if my newborn has stools that begin to have a yellowish color to them." (pick this one)
The nurse is auscultating the lungs of a lethargic, irritable 6-year-old boy and hears wheezing. The nurse will most likely include which teaching point if the child is suspected of having asthma?
"I'm going to have this hospital worker take a picture of your lungs."
During an extended stay in a hospital the nurse has observed a 5-year-old having several temper tantrums. How should the nurse address this behavior with the parents?
"Is it common for your child to throw temper tantrums at home? We have observed this behavior several times here."
The nurse is taking a health history for a 12-year-old child whose BMI is greater than 30. Which general question should the nurse ask the child's parents?
"Is there a family history of hypertension, heart disease, or diabetes?
The mother of an 18-month-old girl voices concerns about her child's social skills. She reports that the child does not play well with others and seems to ignore other children who are playing at the same time. What response by the nurse is indicated?
"It is normal for children to engage in play alongside other children at this age."
The nurse is preparing to assess the internal ear structures of a 3-year-old. The child is resistant to the otoscope. How should the nurse respond?
"Let's see if I can find some puppies or kittens."
A school nurse has completed an educational program for parents of preschool children. Which statement by a participant indicates a need for further education?
"My 5-year-old son still needs me to dress and undress him."
The nurse is teaching a group of caregivers of school-age children about the importance of setting a consistent bedtime for the school-age child. Which statement made by a caregiver indicates an understanding of the sleep patterns and needs of the school-age child?
"My child sleeps between 11 and 12 hours a night."
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?
"My husband gave the baby a special bear that I will place in the crib."
The father of a toddler tells the nurse that his child had a fever the previous night. During the assessment, which statement by the father indicates further discussion is necessary regarding temperature measurement?
"My mother said she always used a glass thermometer when I was a kid and it was very accurate. Maybe that would be better."
A nurse is assisting in a parent education class on accident prevention. Which statement by a parent indicates that further education is needed?
"My son can let his friend ride as a passenger on his bicycle as long as they both wear helmets."
The parents of a 10-year-old tell the clinic nurse that they are concerned because they noticed that their child has gained about 10 pounds over the past 2 years. What is the best response by the nurse?
"Normal growth and development for this age results in an average weight gain of 7 pounds per year."
The nurse is discussing an adolescent's development with the client's parents. Which statement by the parents indicate an understanding of the nurse's teaching?
"Our adolescent is working toward achieving a sense of personal identity."
A 14-year-old boy has come to his primary care physician's office for a routine well-child visit with his parent. Which statement by the parent should the nurse prioritize for further investigation after noting the father has a history of alcohol use disorder?
"Our next door neighbor is older than my son, and he drinks when they hang out together."
The parents of a 10-year-old child report having an issue with their child. One parent reports the child is not a talented athlete but the other parent continues to encourage the child to play and try to excel, stating that sports will "help the child build character." What response by the nurse is most appropriate?
"Perhaps another pursuit would be better suited for your child."
During a health history assessment, the mother of a 10-year-old girl tells you that her daughter does not have time to "play" because she is busy going to gymnastics, cheerleading, art class, flute lessons, reading club, and soccer. What should the nurse's response be?
"Play helps children to develop cognitively, socially, physically, and emotionally."
The nurse is explaining to a group of nursing students the proper technique for obtaining an accurate temperature on a child. The instructor determines the session is successful when the students correctly choose which factor as related to taking a temperature
"Rectal temperatures should not be taken on a child with diarrhea."
An adolescent's parent states not knowing what to do with the adolescent. The parent reports the teenager is taking two or three showers a day when not that long ago the parent could barely get the teen to take a shower at all. What should the nurse's reply be to the parent?
"Reinforce the family rules but also allow the adolescent to develop one's own routine
The nurse is providing teaching to the mother of a 4-year-old girl about bike safety. Which statement by the mother indicates a need for further teaching?
"She can ride on the street if I am riding with her.
The parents of a 4-year-old girl tell the nurse that their daughter is having frequent nightmares. Which statement indicates that the girl is having night terrors instead of nightmares?
"She screams and thrashes when we try to touch her."
The nurse has completed an education program on normal communication abilities in the preschool-age child. Which statement by a participant indicates a need for further education?
"Stating their name and address is too hard for my 5-year-old child; it will be another year before they can do that.
The nurse is caring for a 10-year-old girl and is trying to obtain clues about the child's state of physical, emotional, and moral development. Which question is most likely to elicit the desired information?
"Tell me about your favorite activity at school?"
The nurse is providing anticipatory guidance to the parents of a 15-year-old who voice concerns with their teenager's sleep habits. They state, "Left to her own devices, I'm sure she'd stay up until 3:00 in the morning on the weekends and sleep until after lunchtime." Which should the nurse explain to the parents?
"That must be hard for you to manage. Perhaps we can explore some strategies with her to establish more predictable sleep patterns."
A 15-year-old client's parent comments on the fact that the adolescent seems to always choose the opposite of what everyone else wants and that mood swings are a common occurrence. What statement shows the nurse that the client's parent understands these changes?
"This is common for this age group and it will get better with time.
A mother brings her 8-year-old daughter into the doctor's office because over the past year her tonsils have increased in size to the point that the mother is concerned that her breathing will be obstructed. The girl has no pain, fever or other symptoms. Following this data collection, which instruction is best?
"This may be normal growth of lymphatic tissue for this age."
The mother of a 15-month-old son is returning to work and wants to place her son in the day care close to work; however, they will only accept potty-trained children. Which response from the nurse will best address this situation in answering the mother's questions of how best to potty train her son?
"Wait a few more months until your son has more muscle control and shows signs that he's ready to be potty trained
A nurse is providing a routine wellness examination for a 5-year-old boy. Which response by the parents indicates a need for an additional referral or follow-up?
"We often have to translate his speech to others.
During an admission assessment, the nurse is discussing the developmental level of the child with the parents. Which comment(s) by the parents confirm they are aware of developmental expectations of the preschool-age child? Select all that apply. (ALL ARE CORRECT)
"We think it is important to have play dates with our friend's preschool-age children." (pick this one)
The parents of a 9-year-old child voice concern that the child seems to be gaining weight rapidly. The nurse reviews the medical record and notes the child has increased weight by 6 or 7 lb (2.7 to 3.2 kg) per year for the past 2 years. What response by the nurse is indicated?
"Weight gains of about 7 lb (3.2 kg) per year are normal for children in this age range."
A group of caregivers are discussing the form of discipline in which the child is placed in a "time-out" chair. Which statement made by these caregivers is appropriate related to this form of discipline?
"When my child starts getting frustrated and aggressive, I remind the child throwing a fit will end up in a time-out
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.
The nurse is speaking with the parent of a 4-year-old child. Which statement by the parent would suggest a need for further investigation?
"When we go to the park, my child never wants to play with the other children."
An adolescent who is depressed states, "Nothing ever seems to be right in my life." How should the nurse respond?
"You are feeling sad right now. It is a hard time."
During the first visit to the pediatrician's practice the nurse is performing an admission interview and assessment of a 4-week-old infant. The mother states, "I am sure my baby girl knows my smell because she is much more settled in my arms rather than my mother's arms when she is upset." What is an appropriate response by the nurse?
"You may be right, since infants can sense their mother's smell as early as 7 days old."
A 7-year-old child has taken money from a sibling's dresser on two occasions. When counseling the parent about this behavior, what would the nurse advise?
"You may need to remind your child about property rights."
The school nurse is assessing a 15-year-old female client. The client states, "I just want to be pretty and to look like everyone else." Which response by the nurse is appropriate?
"You seem concerned. Let's talk about your feelings.
A 3-year-old child is hospitalized. The parents are concerned because the child is now refusing to use the potty and is wetting the bed even though the child has achieved toilet training. Which response by the nurse is most appropriate?
"Your child is experiencing regression as a result of stress."
The mother of a 3-year-old tells the nurse that she is concerned that her child is not developing motor skills quickly enough. She states that, "My son can't skip and cannot stand on one foot for any length of time while playing." How should the nurse respond?
"Your child is not expected to be able to perform those activities at 3 years of age.
A parent brings a 6-year-old to the clinic and informs the nurse that the child is tired all the time, even though the child sleeps 7 to 8 hours each night. What is the best response by the nurse?
"Your child should be getting 11 to 12 hours of sleep per night with some quiet time after school."
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. What should the nurse say to the parents?
"Your daughter is demonstrating fine motor skills appropriate to her age by pointing with her index finger.
The infant weighs 6 lb 8 oz (2,950 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 12 months?
19 lb 8 oz (8825 g)
A nurse is reviewing the physical exam of a child. The nurse notes that the child's deep tendon reflexes were normal, because they were graded as:
2+
The nurse is conducting a well-child examination of a 4-year-old and is assessing the child's height. By how much should the nurse expect the child's height to have increased since last year's examination?
2.5 to 3 inches (6.35 to 7.62 cm)
The infant weighs 7 lb 4 oz (3300 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?
21 lb 12 oz (9.9 kg)
A nurse realizes the importance of nutritional assessment during the health history. When doing so, the nurse must assess the quality as well as quantity of food eaten. The best way to assess food intake is to do a:
24 hour recall
The nurse is assessing a 1-year-old at the well-child annual visit and notes the child is meeting the growth parameters. After noting the birth weight was 8 pounds (3.6 kg) and length was 20 inches (50.8 cm) long, which measurements reflecting height/weight would the nurse expect to document for this visit?
24 pounds (10.8 kg) and 30 inches (75 cm)
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 the infant at the age of 6 months?
27.5 in (70 cm)
While auscultating the heart sounds of a child, the nurse hears the S2 "dub" sound loudest at which location?
2nd intercostal space
Blood pressure monitoring becomes part of the routine health assessment at what age and older?
3 years
A pediatric nurse is providing care to several children. The nurse is reviewing the assessment findings for each of the children. Which finding requires the nurse to intervene?
3-year-old preschool-aged child who goes up stairs on hands and knees
What is the correct amount of wet diapers a mature infant should produce each day?
6-8
The parent of a 2-year-old client states it is the child's naptime. The child is refusing to take a nap and cries, "I have to put my babies to sleep first!" The parent states, "I am so sorry, I do not know what is wrong. My child does not act this way at home. My child has 2 baby dolls we rock to sleep each day at home before nap." Which response by the nurse is most appropriate?
A 2-year-old child's behavior can be greatly altered if rituals are not maintained."
The student nurse is preparing a presentation on signs of developmental delay in preschoolers. Which examples of delays should be included? Select all that apply (ALL ARE CORRECT)
A 5-year-old that cannot use plurals or past tense when speaking. (pick this one)
The nurse is caring for a toddler who was just diagnosed with a hearing impairment. What would the nurse expect to assess in the child?
A delay or lack of clear, understandable speech pattern
A hospitalized 7-year-old is recovering from a head injury. Occupational therapy has been ordered to assist the child in regaining eye/hand coordination. If the child cannot master this skill, what feelings may arise?
A feeling of inferiority
The nurse is meeting with a group of caregivers of adolescents and discussing sex and sexuality, including how to discuss these issues with their children. Which comment should the nurse prioritize with this group of caregivers?
Being honest and straightforward with teenagers will encourage them to ask about subjects like sexuality.
The nurse is providing parental anticipatory guidance to promote healthy emotional development in a 12-month-old boy. Which statement best accomplishes this?
A regular routine and rituals will provide stability and security.
The nurse at an elementary school is explaining the concept of industry versus inferiority to a group of nursing students. What is part of this stage of Erikson's theory?
A sense of competence, mastery, and worth
A 17-year-old female is meeting with the nurse for an annual well-visit and is asking the nurse questions about how to know when one is in love. The nurse should point out which factor to help decide if both individuals have reached a mutual agreement and are ready for an intimate relationship?
A sense of trust and identity
The parents of a 30-month-old toddler have brought the toddler into the emergency department because of a seizure. During the health history, the nurse learns that the toddler was frustrated and angry immediately preceding the seizure. The nurse suspects the toddler had a breath-holding spell. Which parental report suggests breath-holding?
A tantrum preceded the event
The nurse is helping the mother of a 5-month-old boy understand the importance of developmentally appropriate play. Which one of the toys best meets the needs of this child?
A yellow rubber duck for the bath
The nurse is interviewing an adolescent. What should the nurse recognize as an important aspect of interviewing the adolescent?
Adolescents will share more about themselves in a private conversation.
The nurse is assessing a toddler's fine motor skills. Which finding by the nurse could be a safety concern?
Ability to turn door knobs
The 18-month-old toddler has most likely attained which gross motor skill?
Ability to walk independently
Which is the best way for parents to aid a toddler in achieving the developmental task?
Allow the toddler to make simple decisions
The nurse is admitting a 10-year-old for surgery. What action should the nurse prioritize when caring for this child?
Answer questions regarding pain.
What advice should the nurse provide the parent of a toddler, regarding how to handle temper tantrums?
Appear to ignore toddler.
The nurse obtains a rectal temperature for an 11-month-old infant. Which action will the nurse perform?
Apply water-soluble lubricant to the probe.
The nurse is promoting language and cognitive development to the parents of a 3-year-old boy. Which guidance about reading with their child will be most helpful?
Ask child questions while reading
The nurse is collecting data on a 9-year-old child being admitted to the pediatric unit. What is the most appropriate way to gather information from the child's caregiver?
Ask the caregiver questions and document the answers
The nurse is obtaining the health history for a 9-year-old child who has been brought to the ambulatory care clinic with reports of a backache. Which initial action by the nurse is most appropriate?
Ask the child when the pain started.
The parents of a 5-year-old tell the nurse that it "seems like our child is afraid of everything from fireworks to butterflies." What actions should the nurse take? Select all that apply. (ALL ARE CORRECT)
Ask the parents if they can identify anything that may be causing their child be fearful. (pick this one)
The nurse wants to find out how much time a preschooler spends in various activities throughout the day. What should the nurse do to learn this information?
Ask the parents to complete a day history
While assessing a 6-month-old, the nurse notes the posterior fontanel (fontanelle) is open. What action should the nurse take next?
Assess the anterior fontanel (fontanelle)
An adolescent with a new piercing comes to the health center at the school. The client reports feeling hot. Which action will the nurse complete first?
Assess the client for signs of infection.
While treating a minor playground injury for an 8-year-old girl, the school nurse discovers that the injury was the result of bullying. What should be the nurse's first action?
Assess the situation with the help of the school staff and parents.
The nurse is caring for an 18-month-old child. The nurse is aware that the child is which stage according to Erikson?
Autonomy versus shame and doubt
The parents of a 10-year-old girl voice concern to the nurse because their daughter seems to "have a higher amount of body fat" than they expect based on the healthy eating habits and high activity level of the family. What is the best response by the nurse?
Before adolescence the body fat composition of school-age children increases earlier and in greater amounts in girls than in boys."
The nurse is talking with parents of a depressed 16-year-old boy. Which question is of the most importance?
Is there a gun in your home?
A newborn requires skin care that includes bathing. Besides hygiene, what is another reason for bathing the newborn?
Bathing is a time for bonding with the parents.
The nurse is preparing a presentation for a local health fair depicting the differences in maturity between preadolescents. Which differing factor should the nurse prioritize in the presentation?
Boys grow at a slower, steadier rate than do girls.
A group of nursing students are completing a clinical day at a preschool. Which behaviors would they identify as common in this preschool group? Select all that apply. (ALL ARE CORRECT)
Regression (pick this one)
While the nurse is taking a blood pressure on a 4-year-old, the child states that the blood-pressure cuff is too tight and angrily says, "That hurt, you big poo-poo head." What is the most appropriate response by the nurse?
Calmly explain that you don't mean to hurt her, loosen the cuff, and tell her that is isn't nice to call you names.
Parents bring a toddler age 19 months to the clinic for a regular checkup. When palpating the toddler's fontanels (fontanelles), what should the nurse expect to find?
Closed anterior and posterior fontanels (fontanelles)
The nurse is preparing to assess the respiratory rate of a crying 15-month-old boy. To get the most accurate assessment, what approach should the nurse take?
Count after the child stops crying and is comfortable.
The nurse is teaching parents of an 11-year-old child how to deal with the issue of peer pressure regarding the use of tobacco and alcohol. Which suggestion by the nurse provides the best course of action for the parents?
Discuss tobacco and alcohol use and effects with the child.
A nurse is teaching a group of parents of preschoolers about safety. Which information would the nurse include? Select all that apply. (ALL ARE CORRECT)
Do not refer to medicines as candy." (pick this one)
When performing a physical examination on a child, the nurse notes a mirror image in the shape and position of the child's chest and abdomen. Which nursing action is appropriate?
Document the finding in the medical record
The parent of a 2-year-old toddler tells the nurse she needs to constantly scold the toddler for having wet pants. The parent says the toddler was potty trained at 12 months, but since starting to walk, the toddler wets the pants all the time. Which nursing diagnosis would be most applicable?
Deficient parental knowledge related to inappropriate method for toilet training
The charge nurse observes a new graduate nurse assess the cremasteric reflex in an 8-month-old boy. The new graduate nurse strokes the lateral aspect of the thigh. Which action should the charge nurse take?
Demonstrate the appropriate technique
A 6-month-old infant is admitted to the hospital because of a fever. When the nurse obtains a health history, what data would be obtained first?
Details about the fever
A toddler is brought to the pediatric clinic by the caregiver because the child "doesn't feel well." As the nurse interviews the caregiver about why the client is there, which goal is the nurse prioritizing at this point?
Determining the chief complaint
The school nurse is meeting with a 10-year-boy who is concerned about his weight. He reports he doesn't eat much candy but loves fruit, pasta, potatoes, and bread. Which suggestion should the nurse prioritize to help him maintain a healthy weight?
Encourage activities that will increase his physical activity.
A single mother with three young children is reluctant to leave her crying and upset 16-month-old daughter overnight in the hospital but needs to go home to care for the other children. Which suggestion from the nurse will best address the fears and concerns of both the child and mother?
Encourage the mother to give the child a personal item of the mother's to hold on to until she returns and to tell the child a specific time she will return, such as "when breakfast comes in the morning.
The mother of a 4-year-old boy reports her son has voiced curiosity about her breasts. She asks the nurse what she should do. Which information is best for the nurse to give the parent?
Encourage the parent to determine what the child's specific questions are and answer them briefly.
The nurse is providing health-promotion teaching to a group of parents of 4-year-old children at a local day care. What information will the nurse include in this education session? Select all that apply. (ALL ARE CORRECT)
Encourage your preschool-aged child to brush their teeth twice a day with a pea-sized amount of toothpaste. (pick this one)
An 8-year-old boy's foster mother is concerned about three recent cavities found in his permanent teeth and reports the child eats a nutritional diet, doesn't eat junk food, and the town water supply is fluoridated. Which suggestion should the nurse prioritize to this mother in regard to the child's dental health?
Ensure that the child brushes his teeth after each meal and snacks
A 3½-year-old child hits another child in prekindergarten and pushes her down. The mother calls the clinic to ask why her child is so aggressive and asks what to do. The nurse's advice would include which suggestion?
Explain that aggression is a common behavior for a child this age but the child must understand that hurting someone is not acceptable
A 13-month-old child is brought to the clinic for a well-child visit. The child's parent expresses concern that the child has not started to walk yet. What is the best action should the nurse take?
Explain that children can take their first steps as late as 18 months of age.
What foods could a parent provide that would be the most beneficial to support healthy dentition for a school-aged child?
Fish, spinach salad and a glass of milk
When auscultating bowel sounds, which of the following frequencies would the nurse identify as normal?
Five to 10 per minute
A 17-year-old adolescent chats excitedly with the nurse about plans for college and a career. The adolescent states having checked out every college in the region and determined which one is the best fit and would give the adolescent the best career options. The nurse recognizes which developmental aspect in this client?
Formal operational thought
The nurse is educating a new parent regarding nutritional needs for the newborn. Which statement is accurate and should be taught regarding the nutritional needs of a newborn?
Formula is designed to provide similar amounts of calories as breast milk would provide.
The parents of an overweight 2-year-old boy admit that their child is a bit "chubby," but argue that he is a picky eater who will eat only junk food. Which response by the nurse is best to facilitate a healthier diet?
Give him more healthy choices with less junk food available."
The pediatric nurse is careful to monitor and assess the growth and development of all clients. Which characteristic should the nurse prepare to assess in the infants?
Grows and develops skills more rapidly than at any other time in their life.
A nurse is performing a health history on a 6-year-old child with asthma. When it comes to identifying if the child is up to date on the immunization schedule, which question would be avoided as it is considered leading?
Have you kept the child up to date on all of the immunizations suggested?
The parents of a 16-year-old male are worried about recent changes in his behavior, ignoring his schoolwork and sports, and spending almost all of his free time interacting with his girlfriend. Which suggestion should the nurse point out would best address this situation?
He has developed his own identity by now; being able to establish close relationships with girls is important preparation for all of his adult relationships. They should honor his need to be with, or talk to, his girlfriend as long as he has completed his schoolwork for the day.
An 8-year-old male child is being seen for a well-child visit. His weight at his visit last year was 50 lb (22.7 kg) and his height was 47 in (119 cm). If he is developing normally, which finding will the nurse expect to note this year?
Height 49.5 in (124 cm
The nurse sees a 15-month-old at a health maintenance visit. Of the following assessments, which one is generally included in a 15-month checkup?
Height and weight measurements
The nurse is caring for a preschool-aged child who needs a CT scan. Which action would the nurse use to best prepare the child for this diagnostic test?
Help the child to pretend that the CT scan machine is a camera.
The nurse has completed an examination of a 32-month-old girl with normal gross and fine motor skills. Which observation would suggest the child is experiencing a problem with language development?
Her vocabulary is between 10 and 15 words.
A nurse is taking a health history on a new family at the pediatric clinic. Which information is the priority information to gather for a complete history database?
Immunization record
The school nurse is developing a school wellness program to promote healthy eating habits and regular physical activity. What is the most important element to emphasize to maximize compliance, healthy habits, and long-term change?
Include both parents and children in the wellness program.
The nurse is educating the mother of a 6-month-old boy about the symptoms for teething. Which symptom would the nurse identify?
Increased biting and sucking
An 8-year-old boy who says he wants to be a doctor when he grows up pleads with the nurse to let him put on his own band-aid after receiving an injection. The nurse agrees and watches as the boy very carefully lines the band-aid up with the mark left by the injection and applies it to his skin. Then he asks, "Did I do it right?" and waits eagerly for the nurse's feedback. The nurse recognizes in this situation the boy's attempt to master the primary developmental step of school age. What is that step?
Industry
Which would be a nutritional goal for a preschool client?
Introduce new food gradually and include variety.
An infant is breastfed. When assessing the stools, which findings would be typical?
Less constipation than bottle-fed infants
The nurse is meeting with a group of caregivers of adolescents. Which example should the nurse point out is most effective for the caregiver to support the adolescent?
Let them choose their hairstyle, even though it may not look the best for them.
The nurse is observing several children interacting during a community health event. Which observed behavior would be indicative of a 4-year-old child?
Look! I am a nurse, and I am helping people feel better!"
The nurse is examining an infant who is 4 days old. The nurse puts the infant in a semi-upright position and lets the head fall back (with immediate support). What infant reflex is the nurse testing?
MORO
The nurse is providing helpful feeding tips to the mother of a 2-week-old boy. Which recommendations will best help the child feed effectively?
Maintain a feed-on-demand approach.
What anticipatory guidance can the nurse provide the girl who has noted the development of breast buds?
Menarche should follow in about 2 years.
The parent of a 3-month-old infant is concerned because the infant does not yet sit by oneself. Which statement best reflects average sitting ability?
Most infants do not sit steadily until 8 months; this infant is normal
The nurse is assessing the newborn. Which would the nurse assess to be an abnormal finding?
Natal teeth noted in the mouth that are loose
The nursing instructor is leading a discussion on school-aged children. The instructor determines the session is successful when the students correctly choose which factor as being a priority for the school-aged child?
Needs 10 to 12 hours of sleep per night
The nurse is caring for a 15-year-old male client. The nurse notes the client's height is 47.5 in (120.65 cm) and weight is 112 lb (50.8 kg). Which action will the nurse take next?
Notify the primary health care provider.
The mother of a 10-year-old daughter is concerned that her child is becoming overweight. Her weight plots in the 95th percentile in the growth chart. Which action would the nurse recommend to the mother to address her concerns?
Offer to go walking every day after school with her for 30 minutes.
A young client is admitted with a fever, vomiting, and diarrhea. Upon taking the health history, the nurse asks the client's parent, "What did you do to help your child before coming to health facility?" This is an example of which type of question?
Open-ended
A nurse is caring for a hospitalized 10-year-old child. What would be an appropriate activity for this child to meet the developmental tasks of this age group?
Participating in a craft project
While caring for a 16-year-old client expected to be hospitalized for several months, the nurse will perform which action to assist the client in meeting the current stage of psychosocial development?
Permit peers to visit during open visitation hours
A nurse realizes safety teaching has been successful when the parents identify which action to help prevent the leading cause of death in preschoolers?
Place child in approved car seat
The nurse is presenting an in-service training to a group of pediatric nurses on the topic of play. The nurse determines the session is successful when the group correctly chooses which example as best displaying toddlers playing?
Playing independently and are side by side
A parent tells a nurse that the child has recently established some friendships for the first time. In which age group do you expect this child to be?
Preschool
The nurse has brought a group of preschoolers to the playroom to play. Which activity would the nurse predict the children to become involved in?
Pretending to be mommies and daddies
A female client tells the nurse about noticing an increase in weight and fat deposits during the past year. The nurse reviews the client's chart and recognizes that the client is most likely going through puberty. Which nursing action is most appropriate at this time?
Provide reassurance that these are normal changes
Parents of a toddler describe how they handled their child's temper tantrum in a shopping mall. What action of the parents indicates need for additional teaching?
Reasoned with the child to stop the behavior
The nurse is teaching the parents of a preschool-age child about injury prevention. Which method would the nurse advise for the parents as the best way to enforce injury prevention?
Repetition and reinforcement
The mother of a 9-month-old child reports her child's eyes are often crossed. The nurse confirms this during the examination. What action is indicated?
Report the findings to the physician.
Which activity will the nurse encourage new parents to complete in order to assist their infant in accomplishing Erikson's developmental task for the first year of life? You Selected:
Respond promptly when the infant cries
The best way for an infant's parent to help the child complete the developmental task of the first year is to:
Respond to infant consistently
A nurse is educating a client being discharged with her newborn baby. What is the highest priority item that must be included in the teaching plan?
Restrain the baby in a car seat.
The nurse is caring for a preschool-age child in the hospital with severe developmental delays. The parents have three other younger children at home and both parents work full-time outside the home. The family has just moved to this area. Which nursing diagnosis would be the highest priority in regard to the parents at this time?
Risk for caregiver role strain
The nurse is teaching healthy eating habits to the parents of a 7-month-old girl. Which recommendation is the most valuable advice?
Serve new foods several times.
Which developmental milestone would the nurse expect an 11-month-old infant to have achieved?
Sitting independently
Which milestone would the nurse expect an infant to accomplish by 8 months of age?
Sitting without support
The school nurse is reviewing the chart of a 12-year-old student who has had excessive absences due respiratory infections. What is the best action by the nurse?
Speak with the parents about the unusual increased number of respiratory infections.
What suggestions regarding the evaluation of a childcare center would the nurse share with a preschooler's mother?
Specific program goals to be accomplished should be available.
A 4-year-old is going to finger paint for the first time. What is the best action for the adult supervisor of this activity?
Support whatever child paints
To obtain an accurate heart rate in an infant, what would be most important for the nurse to do?
Take the apical pulse.
The nurse is caring for several clients on the pediatric unit. When interacting with the preschool-age child, which action does the nurse predict will occur?
Takes in new information at a rapid rate and asks "why" and "how"
The nurse is preparing to participate in a community discussion on the needs of the adolescents in the local school. The nurse should point out which goal is the primary concern for these young individuals as the committee makes plans?
Teens are busy developing their own personal identity.
Computer use at home and at school has increased adolescents' comfort in gaining access to and using the Internet. This has expanded their exposure to risks. What potential risks are there for an adolescent to be exposed to?
Teens can be exposed to inappropriate materials, harassment, threats, and potential for molestation
At a physical examination, a nurse asks the father of a 4-year-old how the boy is developing socially. The father sighs deeply and explains that his son has become increasingly argumentative when playing with his regular group of three friends. The nurse recognizes that this phenomenon is most likely due to:
Testing and identification of group role
An overly tired school-aged child enters the school clinic. The nurse asks the child to state the times he/she usually goes to bed at night and wakes up in the morning. The child answers 11:00 PM and 6:00 AM. Which is the best response made by the nurse?
That is not enough sleep. You should get at least 9 to 12 hours of sleep each night."
The nurse is caring for a 17-month-old child admitted to the acute care facility. The child is fretful and becomes calmer when given a tattered blanket from home. What inference can be made about the child's behavior in response to receiving the blanket?
The ability of the child to soothe herself is a positive sign of development
What is the best explanation of Erikson's theory of psychosocial development during adolescence?
The adolescent faces many different decisions during the teen years concerning the future and the adult world.
The nurse is educating a 17-year-old adolescent after a new diagnosis of diabetes. What does the nurse understand about teaching an adolescent?
The adolescent will likely have the greatest influence on one's own decisions.
The nurse is admitting a 15-year-old adolescent to the hospital pediatric unit. What does the nurse recognize as a priority for this adolescent?
The adolescent's need for privacy should be respected
The nurse is assessing a 6-month-old child. The parent asks when the soft area in the child's head will go away. What is the best response by the nurse?
The area is called the anterior fontanel (fontanelle) and typically closes anytime up to 18 months of age.
The nurse is caring for an adolescent athlete who is being seen for a fractured arm. The parent reports that this is the third sports injury in the past 2 years. The parent asks the nurse why the adolescent—who is healthy overall— continues to have injuries. How should the nurse respond?
The bones, joints, and tendons of adolescents are vulnerable to injury due to their rapid state of growth.
The nurse is examining a 3-year-old girl during a regular visit. Which finding would disclose a developmental delay in this child?
The child demonstrates separation anxiety
The nurse is examining a 2-year-old girl for speech and language development. Which finding would suggest a delay in speech development?
The child does not use the names of familiar objects.
The nurse is assessing a healthy 2-year-old client. Which assessment finding most concerns the nurse?
The child speaks in one-word sentences.
When performing an assessment for scoliosis the nurse asks the child to let both arms hang to the sides. Which observations would be an indication the child requires further screening? Select all that apply (ALL ARE CORRECT)
The elbows fall below the level of the iliac crest. (pick this one)
The home health nurse is visiting a 2-year-old client's home. Which finding will cause the nurse to intervene?
The family's medications are located in a kitchen drawer.
The nurse is providing education to a parent about their 20-month-old child's growth. The parent states that their child seems to have such a big head. What information should the nurse include in the response?
The heads of children at this age are large in proportion to the rest of their body.
The nurse is completing a developmental assessment on a 6-month-old infant. Which findings indicate the need for additional follow-up? Select all that apply. (ALL ARE CORRECT)
The infant does not pay attention to noises behind him. (pick this one)
The nurse is meeting with a group of older siblings of infants to discuss various aspects of infant care.The group will be helping the parents with infant care. Which instruction should the nurse prioritize with this group?
The infant sleeps 10 to 12 hours at night and can take two to three naps during the day
The nurse is performing an assessment on a 8-month-old infant. The infant's medical history notes that he was born at 32 weeks' gestation. The infant is progressing normally. At what adjusted age should the nurse expect the infant's developmental accomplishments?
The infant will most likely present with developmental skills consistent with a 6-month-old infant
A parent asks the nurse what symptoms to expect with normal teething in the infant. How should the nurse respond?
The infant's gumline will be tender
The nurse is weighing a 20-month-old child who is in the clinic for a well-child visit. Which action by the nurse would be most appropriate for weighing this child?
The nurse should have the child sit on the scale while keeping a hand close to but not touching the child.
When testing the deep tendon reflexes of a child, a four-point grading scale is used. What would a 1+ result mean for a reflex tested?
The reflex is diminished
The parent of a 1-month-old infant voices concern about the infant's respirations. The parent states the respirations are rapid and irregular. Which information should the nurse provide?
The respirations of a 1-month-old infant are normally irregular and periodically pause.
The nurse is conducting a health screening for a 3-year-old boy as required by his new preschool. Which statement by the parents warrants further discussion and intervention?
The school is quite structured and advocates corporal punishment."
The parents of a 3-year-old boy have asked the nurse for advice about a preschool for their child. Which suggestion is most important for the nurse to make?
The staff should be trained in early childhood development."
The physician has made a notation in the medical record of a 17-year-old that the teen is not demonstrating successful completion of Erikson's stages of development. What behavior would be consistent with this assessment?
The teen is uncertain and frequently unable to make decisions.
When assessing a toddler's language development, what is the standard against which you measure language in a 2-year-old toddler?
The toddler should speak in two-word sentences ("Me go")
The nurse is assessing a 2-year-old toddler. Which observation(s) will alert the nurse that the child may be experiencing a developmental delay? Select all that apply.
The toddler's vocabulary consists of the words "ball," "dadda," "mum," "drink," and "up." & The toddler will not pick up a toy or touch the nose when directed by the nurse.
The nurse is completing an assessment on a 2-year-old child. The nurse notes the presence of a raised reddish purple spot on the back of the child's neck. Which statement about this finding is correct?
These lesions will normally fade as the child ages
The nurse is assessing the sleeping practices of the parents of a 4-month-old girl who wakes repeatedly during the night. Which parent comment might reveal a cause for the night waking?
They put her to bed when she falls asleep
At a routine wellness check, the parent of a 6-month-old infant reports concerns about the infant's feet possibly being deformed. The assessment revealed the infant's feet have a mild in-toe position. What information should be provided to the infant's parent?
This finding is normal for many children; it is the result of positioning in the womb.
A parent is concerned because the toddler refuses to share. What is the nurse's best response to the parent regarding this concern?
This is normal toddler behavior; sharing is learned later
Parents of a preschooler tell the nurse that their child often refuses to go to sleep at night. Which suggestion by the nurse would be helpful? Select all that apply (ALL ARE CORRECT)
Try using a night light in childs room (pick this one)
A nurse is developing a teaching plan for parents of preschoolers about how to address the issue of strangers and safety. Which would the nurse expect to include in the teaching? Select all that apply. (ALL ARE CORRECT)
Urge children never to talk to or accept a ride from a stranger. (pick this one)
The nurse is caring for the family with a 2-month-old boy with colic. The mother reports feeling very stressed by the baby's constant crying. Which intervention would provide the most help in the short term?
Urging the baby's mother to take time for herself away from the child.
A new mother reports that she is exhausted and that the little sleep she gets is determined by her baby. Which suggestion should the nurse prioritize to help the mother establish healthy sleeping patterns in her infant?
Use the crib for sleeping only, not for play activities.
During play time in the community health center the nurse hears several children interacting with the caregivers. Which statement(s) are considered aligned with the communication milestones for a 3-year-od child? Select all that apply. (ALL ARE CORRECT)
Watch cartoon TV (pick this one)
When collecting data on a preschool-aged child during a well-child visit, the nurse discovers the child has gained 12 lb (5.4 kg) and grown 2.5 inches (6.3 cm) in the last year. The nurse interprets these findings to indicate which situation?
Weight is above an expected range and height is within an expected range.
The father of a 6-week-old infant voices concerns about his son's stooling. He further shares that his son grunts and cries when having a bowel movement. What response by the nurse is most appropriate?
What does his stool look like?
When obtaining information from a teen concerning the reason for seeking health care, which question would be most important?
What health concerns are you having?"
The nurse is caring for a parent following the birth of the newborn. The new parent asks the nurse, "When is the best time for me to start bonding with my baby?" Which response by the nurse is appropriate?
You should interact with your newborn when the eyes are open wide and bright."
A mother asks the nurse where the microwave is so that she can warm up breast milk to feed her baby. What is the best response by the nurse?
You should warm the milk under warm water instead."
The father of a 4-year-old is concerned his child is not telling the truth and blaming others for things that have happened. Which response should the nurse prioritize after the father shares that the child is blaming someone named "Andrew" for a broken tool, and they have no idea who this is
Your son may have a friend named Andrew, but it could be an imaginary friend."
The nurse is conducting a support group for parents of 9- and 10-year-olds. The parents express concern about the amount of time their children want to spend with friends outside the home. What should the nurse teach the parents that peer groups provide?
a sense of security as children gain independence
A 15-year-old adolescent is seen at a health care facility for facial acne. When counseling the teen, the nurse would teach that the basic cause of acne is:
activation of androgen hormones.
The school nurse is assessing a 16-year-old girl who was removed from class because of disruptive behavior. She arrives in the nurse's office with dilated pupils and is talking rapidly. Which drug might she be using?
amphetamines
A group of 10-year-old girls have formed a "girls only" club. It is only open to girls who still like to play with dolls. Which factor does this best represent?
appropriate social development
A teenage boy tells the nurse that his parents embarrass him in front of his friends when they kiss him goodbye. The nurse is aware that this teenager is revisiting which stage of development identified by Erikson?
autonomy
The nurse is assessing a 2-year-old boy during a well-child visit. The nurse correctly identifies the child's current stage of Erikson's growth and development as:
autonomy versus shame and doubt
The nurse is assisting with the physical examination on a sleeping 10-month-old infant being held by the parent against the parent's shoulder. In what sequence would the nurse complete the assessment?
back and extremities; head and neck; then the ears, nose, mouth, and eyes
An adolescent female with anemia has been prescribed a diet high in iron. Selection of which meal indicates to the nurse that the client understands the prescribed diet?
baked chicken, steamed cauliflower, garden salad
Anticipatory guidance for an infant for the 4th month should include the fact that the infant will be able to achieve which developmental milestone?
be able to turn over onto the back
The school-age child develops the ability to recognize that if a block of clay is in a round ball and then is flattened, the shape changes but not the amount of clay. What understanding has this child developed?
conservation
A nurse is developing a plan of care for a 4-year-old client with cystic fibrosis who has frequent hospitalizations related to his illness. Which would be the most appropriate nursing diagnosis for this client?
delayed growth and development related to frequent illness
A 6-month-old has fanning of the toes and dorsiflexion of the big toe seen on physical exam. Based on this finding the nurse should:
document as a normal finding.
While observing a group of 9-year-old children at school, the nurse is concerned that one of the children is not cognitively developing according to Piaget's stage of concrete-operational thought processes. With which activity is the nurse concerned?
does not understand the phrase "slow as molasses" when used by the teacher
A type of play seen in preschool children encourages children to act out troubling situations, such as one that might occur in the hospitalized child who must undergo an upsetting procedure. This type of play is referred to as:
dramatic play
The nurse is talking to the parent of a 19-month-old toddler about setting limits and supervising activities. In which situation will the nurse recommend letting the toddler do as he or she pleases?
exploring ones body
The nurse is talking to a 13-year-old boy about choosing friends. Which function do peer groups provide that can have a negative result?
following role models
A parent tells the nurse that no matter what is asked of the toddler, the toddler says, "No." What suggestion might the nurse make to help the parent handle this situation?
give the toddler secondary, not primary, choices
According to Erikson, the adolescent develops their own sense of being an independent person with individual thoughts and goals. This stage is referred to as:
identity vs. role confusion.
A nurse is describing growth and development during the preschool period. What would the nurse identify as a predominant and heightened characteristic for this age group?
imagination
When planning how to respond to a 3-year-old child about telling stories ("tall tales"), the nurse would base the statement on the fact that:
imagination in a 3-year-old is at its peak.
The developmental task of the school-aged period, according to Erikson, is gaining a sense of:
industry versus inferiority.
The family who are vegetarian voice concern that their child is not growing well. The nurse should suggest which food to increase the calcium intake for adequate bone growth?
kale
A staff nurse is talking about Piaget's theory with a nursing student. Infants are in the sensorimotor stage of cognitive development during which object permanence is mastered. An example of an infant displaying this ability is:
looking for a toy in her crib at the last place she saw it
The nurse is assessing the oral cavity of a 6-month-old child. When palpating the location in which the first primary teeth erupt, which location is being assessed?
lower central gumline
A school-aged child develops school phobia. When counseling her mother, the nurse would advise her that the accepted action is to:
make her child attend school every day.
During the physical examination, the nurse notes a positive Kernig and Brudzinski sign. The nurse interprets these findings to suggest which condition?
meningeal irritation
The school nurse is preparing health promotion presentations regarding unintentional injuries for a high school health fair. On which topic should the nurse place as the priority when preparing the presentation?
motor vehicle safety
The nurse is assessing the oral cavity of a 4-month-old infant. Which finding is consistent with a child of this age?
no teeth
Nurses should provide anticipatory guidance to males to prepare them for what particular pubertal change in middle-to-late adolescence?
nocturnal emissions
A parent and their 4-year-old child are waiting in an exam room when the nurse enters and greets and observes them. Which activity of the child best demonstrates the primary developmental task of the preschool-age child, according to Erikson?
opening drawers in the room, pulling out and examining supplies
The nurse is supervising a play group of children on the unit. The nurse expects the toddlers will most likely be involved in which activity?
playing with the plastic vacuum cleaner and pushing it around the room
During a well-child check at the ambulatory clinic, the mother of a 10-year-old boy reports concerns about her son's frequent discussions about death and dying. Based upon knowledge of this age group, the nurse understands that:
preoccupation with death and dying is common in the school-aged child
The nurse is conducting a well-child assessment of a 4-year-old. Which assessment finding warrants further investigation?
presence of 10 deciduous teeth
A mother tells the nurse she is having difficulty getting her 6-year-old to do chores. Based on the child's developmental level, what activity would be best for the nurse to recommend to the mother?
putting books on shelf
The nurse is teaching the parents of a 6-month-old infant about proper dental care. Which action will the nurse indicate as most likely to cause dental caries in this infant?
putting the infant to bed with a bottle of milk or juice
During a well-child visit to the health care provider, the parent reveals a family struggling with the changes from their "sweet, cuddly 16-month-old child" to that of a negative, more aggressive 2-year-old toddler. After the clinic visit, the nurse will document which priority nursing focus for this visit?
ready for enhanced family coping
A nurse assesses the skin of a child and documents evidence of plethora. Which finding did the nurse observe?
redness of the cheeks and lips
The school nurse receives a report that a child is having difficulty with grades and always appears hungry. When the nurse is assessing this child, what information would be most important to ascertain?
relationship with parents
A 2-year-old toddler holds his breath until passing out when he wants something the parent does not want him to have. The nurse would decide whether these temper tantrums are a form of seizure based on the fact that:
seizures are not provoked; temper tantrums are
The nurse conducting a 6-month well-baby check-up assesses for the presence/absence of the asymmetric tonic neck reflex. At this age the reflex:
should have disappeared.
The nurse is assessing the language development of a 3-year-old girl. Which finding would suggest a problem?
speaks in 2- to 3-word sentences
The nurse is examining the genitals of a healthy newborn girl. The nurse should observe which normal finding?
swollen labia minora
When assessing the growth and development of a 4-year-old, which would the nurse note as being appropriate?
tells a fantasy story about a bear and a car
The nurse is conducting a complete physical assessment of an early adolescent. Which finding leads the nurse to conclude this adolescent is experiencing the first changes of puberty?
testicular enlargement
A 5-month-old infant being assessed was born at 32 weeks. The nurse doing the well-child check-up should compare the baby to what norms?
the development of a 3-month-old
Where is the point of maximal impulse (PMI) found in a 5-year-old child
the fourth intercostal space
The nurse is educating the mother of a newborn about feeding practices. The nurse correctly advises the mother that:
the newborn's stomach can hold between 0.5 oz and 1 oz.
A mother expresses surprise to the nurse that her 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 nurse is caring for a 4-year-old girl following an appendectomy. The girl becomes fearful and starts to cry as soon as the nurse walks into the room. When the nurse asks about the crying, the girl says, "Nurses who wear shirts with flowers give shots." The nurse understands that this statement is an example of:
transduction
The nurse is assessing an infant at the 6-month well-baby check-up. The nurse notes that at birth the baby weighed 8 lb (3600 g) and was 20 in (50.8 cm) in length. Which finding is consistent with the normal infant growth and development?
weight of 16 lb (7300 g) and length of 26 in (66.0 cm)
The nurse is preparing a safety presentation for a health fair for families. Which instruction should the nurse prioritize when illustrating car safety and the family?
"Set a good example. Wear your own seat belt every time you drive
