Test 1

The nurse is developing a nursing care plan for a hospitalized 6-year-old. Which behavior would warrant nursing intervention?

The child does not want to play games with other children on the hospital ward.

The nurse is assessing a 2-year-old boy who has missed some developmental milestones. Which finding will point to the cause of motor skill delays?

The child is homeless and has no toys.

The nurse is observing a 24-month-old boy in a day care center. Which finding suggests delayed motor development?

The child is unable to push a toy lawnmower.

The nurse is supervising lunch time for children on a pediatric ward. Which observation is considered abnormal for this age group?

The child uses his fingers and refuses to use a fork.

The nurse is examining a 10-month-old boy who was born 10 weeks early. Which finding is cause for concern?

The child's head circumference is 19.5 inches.

The neonatal nurse assesses newborns for iron-deficiency anemia. Which newborn is at highest risk for this disorder?

A premature newborn

The nurse is assessing a 12-month-old boy with an English-speaking father and a Spanish-speaking mother. The boy does not say mama or dada yet. What is the priority intervention?

Asking the mother if the child uses Spanish words

A new mother expresses concern to the nurse that her baby is crying and grunting when passing stool. What is the nurse's best response to this observation?

'This is normal behavior for infants unless the stool passed is hard and dry.'

The nurse is assessing a 3-year-old boy's development during a well-child visit. Which response by the child indicates the need for further assessment?

He laughs when his brother cries getting vaccinated.

A nurse is caring for a 4-year-old girl. The mother says that the girl is afraid of cats and dogs and does not like to go to the playground anymore because she wants to avoid the dogs that are often being walked at the park. What should the nurse tell the mother?

"Acknowledge her fear and help her develop a strategy for dealing with it."

The nurse is teaching good sleep habits for toddlers to the mother of a 3-year-old boy. Which response indicates the mother understands sleep requirements for her son?

"He needs 12 hours of sleep per day including his nap."

The parents of a 5-year-old boy tell the nurse that their son is having frequent episodes of night terrors. Which of the following statements would indicate that the boy is having nightmares instead of night terrors?

"He will tell us about what happened in his dream."

The nurse is watching toddlers at play. Which normal behavior would the nurse observe?

Toddlers engage in parallel play.

The nurse is providing anticipatory guidance to the mother of a 9-month-old girl during a well-baby visit. Which topic would be most appropriate?

Advising how to create a toddler-safe home

The nurse is explaining to parents that the preschooler's developmental task is focused on the development of initiative rather than guilt. What is a priority intervention the nurse might recommend for parents of preschoolers to stimulate initiative?

Reward the child for initiative in order to build self-esteem.

The pediatric nurse is planning quiet activities for hospitalized 18-month-old. What would be an appropriate activity for this age group?

Stacking blocks

A mother is concerned about her infant's spitting up. Which suggestion would be most appropriate?

"Keep the baby sitting up for about 30 minutes afterward."

The nurse is providing teaching about car safety to the parents of a 5-year-old girl who weighs 45 pounds. What should the nurse instruct the parents to do?

"Place her in a booster seat with lap and shoulder belts in the back seat."

The mother of a 4-year-old boy tells the nurse that her son occasionally wets his pants during the day. How should the nurse respond?

"Tell me about the circumstances when this occurs."

The nurse is designing a nursing care plan for a toddler with lymphoma, who is hospitalized for treatment. What is a priority intervention that the nurse should include in this child's nursing plan?

Monitoring the toddler for developmental delays

The nurse is teaching the parents of a 4-year-old boy about the normal maturation of the child's organs during the preschool years and their effect on body functions. Which statements accurately describe these changes? Select all that apply.

Myelination of the spinal cord allows for bowel and bladder control to be complete in most children by age 3 years. The respiratory structures are continuing to grow in size, and the number of alveoli continues to increase, reaching the adult number at about 7 years of age. The bones continue to increase in length and the muscles continue to strengthen and mature; however, the musculoskeletal system is still not fully mature. The small intestine is continuing to grow in length, and stool passage usually occurs once or twice per day in the average preschooler.

The nurse is describing the maturation of various organ systems during toddlerhood to the parents. What would the nurse correctly include in this description?

Myelinization of the brain and spinal cord is complete at about 24 months.

The parents of a 1-year-old girl, both of whom have perfect teeth, are concerned about their child getting dental caries. Which is the best advice the nurse can provide?

Tell the parents to limit the child's eating to meal and snack times.

The nurse is caring for a 4-week-old girl and her mother. Which is the most appropriate subject for anticipatory guidance?

Telling how and when to introduce rice cereal

The nurse is providing guidance after observing a mother interact with her negative 2-year-old boy. For which interaction will the nurse advise the mother that she is handling the negativism properly?

Telling the child firmly that we don't scream in the office

The nurse is performing a cognitive assessment of a 2-year-old. Which behavior would alert the nurse to a developmental delay in this area?

The child does not point to named body parts.

The nurse observing toddlers in a day care center notes that they may be happy and pleasant one moment and overreact to limit setting the next minute by throwing a tantrum. What is the focus of the toddler's developmental task that is driving this behavior?

The need for separation and control

The nurse is teaching a new mother about the development of sensory skills in her newborn. What would alert the mother to a sensory deficit in her child?

The newborn does not respond to a loud noise.

The nurse is testing the sensory development of a toddler brought to the clinic for a well visit. What might alert the nurse to a potential problem with the child's sensory development?

The toddler does not respond to commands whispered in his ear.

When providing anticipatory guidance to parents about their preschool son who was caught in a lie, what would the nurse emphasize?

"You need to determine the reason for lying before punishing the child."

The parents of a 4-year-old ask the nurse when their child will be able to differentiate right from wrong and develop morals. What would be the best response of the nurse?

'The preschooler is developing a conscience.'

The nurse is interviewing a 3-year-old girl who tells the nurse: 'Want go potty.' The parents tell the nurse that their daughter often speaks in this type of broken speech. What would be the nurse's appropriate response to this concern?

'This is a normal, common speech pattern in the 3-year-old and is called telegraphic speech.'

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

'This is a primitive reflex known as the palmar grasp.'

The parent of a 6-month-old infant asks the nurse for advice about his son's thumb sucking. What would be the nurse's best response to this parent?

'Thumb sucking is a healthy self-comforting activity

The nurse is providing teaching about accidental poisoning to the family of a 3-year-old. The nurse understands that a child of this age is at increased risk of accidental ingestion due to which sensory alteration?

A less discriminating sense of taste

The nurse is providing anticipatory guidance to a mother of a 5-month-old boy about introducing solid foods. Which statement by the mother indicates that effective teaching has occurred?

"The cereal should be a fairly thin consistency at first."

The mother of a 5-year-old boy calls the nurse and seeks advice on how to assist the child with the recent death of his paternal grandfather. The boy keeps asking when his grandpa is coming back. How should the nurse respond?

"This is normal; children his age do not understand the permanence of death."

After teaching a group of parents about language development in toddlers, what if stated by a member of the group indicates successful teaching?

"When my 3-year-old asks 'why?' all the time, this is completely normal."

At which age would the nurse expect to find the beginning of object permanence?

6 months

When instructing the parents of a toddler about appropriate nutrition, what would the nurse recommend?

Approximately 16 to 24 ounces of milk per day

Which activity would the nurse least likely include as exemplifying the preconceptual phase of Piaget's preoperational stage?

Beginning questioning of parents' values

The parents of a 2-year-old girl are frustrated by the frequent confrontations they have with their child. Which is the best anticipatory guidance the nurse can offer to prevent confrontations?

"You need to adhere to various routines."

The nurse is assessing the developmental milestones of an infant. The infant was born 8 weeks ago and was 4 weeks premature. The nurse anticipates that the infant will be meeting milestones for what age of child? Record your answer in weeks.

4

The nurse is conducting a well-child examination of a 5-year-old girl, who was 40 inches tall at her last examination at age 4. Which height measurement would be within the normal range of growth expected for a preschooler?

43 inches

The nurse is developing a teaching plan for toddler safety to present at a parenting seminar. Which safety intervention should the nurse address?

Advise parents to use a forward-facing car seat with harness straps and a clip, placed in the backseat of the car.

The nurse is providing anticipatory guidance to the parents of an 18-month-old girl. Which guidance will be most helpful for toilet teaching?

Advising them to use praise, not scolding

The nurse is assessing the infants in the nursery for the six stages of consciousness. The nurse becomes concerned when assessing which infants? Select all that apply.

An infant rapidly moves from deep sleep to crying An infant moves from active alert state to drowsiness An infant frequently skips the quiet alert state during the six stages of consciousness

The nurse observes an infant interacting with his parents. What are normal social behavioral developments for this age group? Select all that apply.

Around 2 months the infant exhibits a first real smil Around 3 months the infant smiles widely and gurgles when interacting with the caregiver. Around 3 months the infant will mimic the parent's facial movements, such as sticking out the tongue. Separation anxiety may also start in the last few months of infancy.

The nurse caring for newborns knows that infants exhibit phenomenal increases in their gross motor skills over the first 12 months of life. Which statements accurately describe the typical infant's achievement of these milestones? Select all answers that apply.

At 1 month the infant lifts and turns the head to the side in the prone position. At 7 months the infant sits alone with some use of hands for support. At 9 months the infant crawls with the abdomen off the floor. At 12 months the infant walks independently.

The nurse is teaching a new mother the proper techniques for breastfeeding her newborn. Which is a recommended guideline that should be implemented?

Bring the baby's wide-open mouth to the breast to form a seal around all of the nipple and areola.

The nurse is teaching a new mother about the drastic growth and developmental changes her infant will experience in the first year of life. Which statement describes a developmental milestone occurring in infancy?

By 6 months of age the infant's brain weighs half that of the adult brain; at age 12 months, the brain weighs 2.5 times what it did at birth.

What activity would the nurse expect to find in an 18-month-old?

Climbing stairs with assistance

The parents of a 4-year-old who is a picky eater ask the nurse what foods to include in their child's diet to provide adequate iron consumption. Which food would the nurse recommend?

Cooked lentils

The nurse is caring for preschoolers in a day care center. For this age group, of what developmental milestones should the nurse be aware? Select all that apply.

Counting 10 or more objects Correctly naming at least four colors Understanding the concept of time Knowing everyday objects

The nurse emphasizes that a toddler younger than the age of 18 months should never be spanked primarily for which reason?

There is an increased risk for physical injury in this age group.

The nurse is promoting a healthy diet to guide a mother when feeding her 2-week-old girl. Which is the most effective anticipatory guidance?

Discouraging the addition of fruit juice to the diet

A 6-month-old girl weighs 14.7 pounds during a scheduled check-up. Her birth weight was 8 pounds. What is the priority nursing intervention?

Discussing the child's feeding patterns

The nurse is caring for a 7-month-old girl during a well-child visit. Which intervention is most appropriate for this child?

Discussing the type of sippy cup to use

The nurse is providing discharge teaching regarding formula preparation for a new mother. Which guideline would the nurse include in the teaching plan?

Do not add cereal to the formula in the bottle or sweeten the formula with honey.

The nurse is teaching parents interventions appropriate to the emotional development of their toddlers. What is a recommended intervention for this age group?

Do not blame toddlers for aggressive behavior; instead, point out the results of their behavior.

The nurse is assessing the motor skills of a 5-year-old girl. Which finding would cause the nurse to be concerned?

Draws a person with three body parts

The nurse is teaching the parents of a 2-year-old toddler methods of dealing with their child's 'negativism.' Based on Erickson's theory of development, what would be an appropriate intervention for this child?

Encourage the child to pick out his own clothes.

The nurse is educating a first-time mother who has a 1-week-old boy. Which is the most accurate anticipatory guidance?

Explaining that the stomach holds less than 1 ounce

The nurse is helping parents prepare a healthy meal plan for their toddler. Which guidelines for promoting nutrition should be followed when planning meals? Select all that apply.

Extending breastfeeding into toddlerhood is believed to be beneficial to the child. Adequate calcium intake and appropriate exercise lay the foundation for proper bone mineralization. The toddler requires an average intake of 500 mg calcium per day.

The nurse is teaching the parents of a 2-year-old girl how to deal with common toddler situations. Which is the best advice?

Have the child help clean up a bowel accident.

The nurse is caring for a toddler who is in Piaget's sensorimotor stage of cognitive development. Which task would the nurse expect the toddler to be able to perform?

Knowing which are his or her toys

The nurse is conducting a well-child assessment for a 5-year-old boy in preparation for kindergarten. The boy's grandmother is his primary caregiver because the boy's mother has suffered from depression and substance abuse issues. The nurse understands that the child is at increased risk for which developmental problem?

Lack of social and emotional readiness for school

The nurse is performing a health assessment of a 3-month-old African-American boy. For what condition should this infant be monitored based on his race?

Lactose intolerance

The nurse is caring for a 5-year-old girl posttonsillectomy. The girl looks out the window and tells the nurse that it is raining and says, "The sky is crying because it is sad that my throat hurts." The nurse understands that the girl is demonstrating which mental process?

Magical thinking

The nurse in a community clinic is caring for a 6-month-old boy and his mother. Which intervention is priority to promote adequate growth?

Monitoring the child's weight and height

When observing a group of preschoolers at play in the clinic waiting room, which type of play would the nurse be least likely to note?

Parallel play

The nurse is providing anticipatory guidance to a mother to help promote healthy sleep for her 3-week-old baby. Which recommended guideline might be included in the teaching plan?

Place the baby on his or her back when sleeping.

The nurse is assessing the psychosocial development of a preschooler. What are normal activities characteristic of the preschooler? Select all that apply.

Plans activities and makes up games Initiates activities with others Acts out roles of other people

The school nurse is helping parents choose books for their preschoolers. What literacy skills present in the preschooler would the nurse consider when making choices? Select all that apply.

Preschoolers enjoy books with pictures that tell stories. Preschoolers like stories with repeated phrases as they help keep their attention. Preschoolers demonstrate early literacy skills by reciting stories or portions of books. Preschoolers may retell the story from the book, pretend to read books, and ask questions about the story.

The nurse is counseling parents of a picky eater on how to promote healthy eating habits in their child. Which intervention would be appropriate advice?

Present the food matter-of-factly and allow the child to choose what to eat.

The nurse is counseling the mother of a newborn who is concerned about her baby's constant crying. What teaching would be appropriate for this mother?

Reducing stimulation may decrease the length of crying.

The nurse is teaching the parents of an overweight 18-month-old girl about diet. Which intervention will be most effective for promoting proportionate growth?

Remove high-calorie, low-nutrient foods from the diet.

Which reflex, if found in a 4-month-old infant, would cause the nurse to be concerned?

Step

The nurse is choosing foods for a toddler's diet that are high in vitamin A. What foods could be added to the menu? Select all that apply.

Sweet potatoes Spinach Carrots

The nurse is assessing a 4-month-old boy during a scheduled visit. Which findings might suggest a developmental problem?

The child does not vocally respond to voices.

A new mother tells the nurse that she is having difficulty breastfeeding her baby. When observing the mother, which actions prompt the nurse to provide teaching about proper breastfeeding techniques? Select all that apply.

The mother carefully washes her breasts prior to feeding the infant. The mother feeds the infant every hour. The mother supplements feedings with water.

The nurse is assessing the respiratory system of a newborn. Which anatomic differences place the infant at risk for respiratory compromise? Select all that apply.

The nasal passages are narrower. The larynx is more funnel shaped. There are significantly fewer alveoli.

The nurse is performing a physical assessment of a 3-year-old girl. What finding would be a concern for the nurse?

The toddler's anterior fontanel is not fully closed.

The nurse of a preschool child is helping parents develop a healthy meal plan for their child. What nutritional requirements for this age group should the nurse consider?

The typical preschooler requires about 85 kcal/kg of body weight.

The nurse is caring for a premature baby in the NICU. The mother reports that the infant's normally happy and outgoing 5-year-old sister is acting sad and withdrawn. The nurse understands that due to her developmental stage, the girl is at risk of what happening?

Viewing her baby sister's illness as her fault

During a health history, the nurse explores the sleeping habits of a 3-year-old boy by interviewing his parents. Which statement from the parents reflects a recommended guideline for promoting healthy sleep in this age group?

We keep a strict bedtime ritual for our son, which includes a bath and bedtime story.'

The parents of a preschooler ask the nurse to help them choose a preschool for their child. What are recommended guidelines and goals for choosing a preschool? Select all that apply.

When selecting a preschool the parent may want to consider the accreditation of the school and the teachers' qualifications. The parent should observe the classroom, evaluating the environment, noise level, and sanitary practices. The parent should observe the classroom to determine how the children interact with each other and how the teachers interact with the children.

Which food suggestion would be most appropriate for the mother of a preschooler to ensure an adequate intake of calcium?

White beans