ATI Peds
A nurse at a clinic is preparing to administer immunizations to a five-year-old child. Which of the following immunizations should the nurse plan to give? A. Diphtheria, tetanus, and pertussis (DTaP) B. Pneumococcal (PCV) C. Haemophilus influenzae type B (Hib) D. Hepatitis B (Hep B)
A
A nurse is caring for a toddler who has gastroenteritis caused by salmonella. Which of the following is the priority action for the nurse? A. Weigh the child B. Initiate contact precautions C. Establish a skin care routine D. Obtain a recent food history
B
A nurse is assessing a preschooler who has HIV. Which of the following manifestations should the nurse expect? A. Generalized petechiae B. Jaundice C. Obesity D. Chronic diarrhea
D
A hospice nurse is conducting a support group for parents of toddlers who have a terminal illness. Which of the following pieces of information should the nurse include in the teaching? A. Toddlers will react to the parents' anxiety and sadness B. Toddlers view death as punishment for bad behavior C. Toddlers view death as permanent and irreversible D. Toddlers have a realistic concept of death
A
A nurse is assessing a school age child after a ventriculoperitoneal (VP) shunt replacement. Which of the following findings indicates a complication of this procedure? A. Abdominal distention B. Unequal peripheral pulses C. Pinpoint pupils D. Frontal bossing
A
A nurse is assessing an 18 month old toddler during a well child examination. Which of the following findings should the nurse report to the provider? A. The toddler is unable to remove his shoes B. The toddler is unable to draw a plus sign C. The toddler is unable to jump off a step D. The toddler is unable to turn one page of a book at a time
A
A nurse is caring for a child who has electrical burns on the lower arms and hands. Which of the following findings indicate the child is experiencing a complication of the injury? A. Dark urine B. 2+ radial pulses C. Respiratory rate of 20/min D. Minimal pain
A
A nurse is caring for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following actions should the nurse take? A. Administer ibuprofen B. Limit daily fluid intake C. Apply cold compresses to painful joints D. Withhold live virus immunizations
A
A nurse is caring for a group of infants with congenital heart defects. For which of the following defects should the nurse expect to observe cyanosis? A. Transposition of the great arteries B. Ventricular septal defect C. Coarctation of the aorta D. Patent ductus arteriosus
A
A nurse is caring for a toddler who is post operative following a cleft palette repair. Which of the following actions should the nurse take? A. Restrain the toddlers arms at the elbows B. Feed the toddler with a spoon C. Monitor the toddlers oral temperature D. Weigh the toddler every 48 hours
A
A nurse is caring for the family of a preschooler who has a terminal illness. The nurse should teach the family to expect the preschooler to have which of the following concepts of death? A. People can come back to life after they die B. Death eventually occurs for all people C. Death is a scary monster that causes people to die D. People are unable to be anything but alive
A
A nurse is creating a plan of care for a child who has a plastic anemia. Which of the following interventions should the nurse include? A. Initiate protective environment isolation for the child B. Apply pressure for 1 to 2 min at the puncture site following blood specimen collection C. Mix the child's Ferrous sulfate elixir or twice per day into a glass of milk for administration D. Check the child's blood glucose level every four hours
A
A nurse is planning care for a four-year-old child who has nephrotic syndrome. Which of the following actions should the nurse take? A. Provide thorough skin care B. Test for blood type and crossmatch C. Allow ample hydrating fluids D. Maintain a low carbohydrate diet
A
A nurse is preparing to feed an infant who has cleft lip and palate. Which of the following actions should the nurse plan to take? A. Burp the infant at least 2 to 3 times during the feeding B. Remove the nipple from the infant mouth if swallowing becomes audible C. Stop the feeding if formula appears in the nasal cavity of the infant D. Discourage the parents from participating in the feeding prior to a surgical repair
A
A nurse is providing dietary teaching to the parent of a toddler who has cystic fibrosis. Which of the following instructions should the nurse include? A. Provide a high fat diet for the toddler B. Limit the toddlers daily intake of sodium C. Increase the toddlers intake of foods high in folic acid D. Allow the toddler to skip meals when he is not hungry
A
A nurse is providing teaching to the parent of a child who has cystic fibrosis in a prolapsed rectum. The nurse should identify that which of the following is a cause of this complication? A. Bulky stools B. Weakened rectal sphincter C. Elevated pancreatic enzymes D. Decreased intra-abdominal pressure
A
A nurse is providing teaching to the parent of a two-year-old toddler about nutrition which of the following statements by the parent indicates an understanding of the teaching? A. "My child should consume 1000 cal per day" B. "My child should have 4 ounces of protein per day" C. "I should give my child 32 ounces (4 cusps) of milk per day" D. "I should feed my child 4 ounces (1/2 cup) of vegetables per day"
A
A nurse is reviewing the medical record of a two month old infant who has rotavirus. The nurses notes a hemoglobin level of 12 g/dL and a hematocrit of 51%. Which of the following statements by the nurse indicates an understanding of the laboratory values? A. The infant might be dehydrated B. The infant might be anemic C. The infant might have received too much fluid D. The infant might have leukemia
A
A nurse is teaching the parents of a child who has rheumatic fever. Which of the following statements by a parent indicates an understanding of the teaching? A. "My child may take aspirin for his joint pain" B. "My child will need a blood transfusion prior to discharge" C. "I will need to wear a gown when I'm in my child's room" D. "I will apply lotion to my child's peeling hands"
A
A nurse is teaching the parents of an infant about treatment options for profound sensorineural hearing loss. The nurse should include which of the following pieces of information about the function of cochlear implant's? A. They provide direct stimulation of the auditory nerve fiber B. They conduct sound waves through the mastoid bone to the cochlea C. They process digital sound to amplify several sound frequencies D. They convert vibrations in the ears structures to electrical signals
A
A school nurse is assessing an adolescent who return to school following a case of mononucleosis. The child has a note from his provider excusing him from gym class. Which of the following findings should the nurse identify as the reason for this excusal? A. Potential for sustaining abdominal trauma B. Deficient dietary intake C. Exposing peers to the illness D. Straining sore joints
A
The nurse is assessing the gross motor skills of a four year old preschooler. The nurse should expect the preschooler to perform which of the following activities? A. Hopping on 1 foot B. Skipping on alternate feet C. Jumping rope D. Rollerskating
A
A nurse is caring for an infant who has a tracheoesophageal fistula. Which of the following actions should the nurse take? A. Place the infant in a lateral position B. Perform oropharyngeal suctioning C. Administer ranitidine orally D. Thicken the infant's formula
B
A nurse is planning care for a 10 month old infant who has suspected failure to thrive (FTT). Which of the following interventions should the nurse include in the plan of care? Select all that apply A. Observe the parents' actions when feeding the child B. Maintain a detailed record of food and fluid intake C. Follow the child's cues to time food and fluids D. Sit beside the child's high chair for feedings E. Play music videos during scheduled meal times
A, B
A school nurse is providing dietary teaching for an adolescent who has type one diabetes mellitus. Which of the following responses by the adolescent indicates an understanding of the teaching? Select all that apply A. "I should eat extra food on busy days when I am more active" B. "I should wait for two hours after eating before going swimming with my friends" C. "I should increase my intake of sugar-free fluids when I am sick" D. "I should eat a snack 30 minutes before my baseball games start" E. "I should have a 16 ounce sports drink if I start feeling weak or shaky"
A, C, D
A nurse is assessing the development of a three-year-old child. Which of the following gross motor skills should the nurse expect the child to be able to perform? A. Skipping around the room B. Hopping on 1 foot C. Throwing a ball overhead D. Standing on 1 foot
D
A nurse in an emergency department is assisting with the care of a four-year-old child who ingested toilet bowl cleaner. The child has hemoptysis, is crying, and states, "it burns". Which of the following actions should the nurse perform? Select all that apply A. Identify how much cleaner was in the bottle B. Administer activated charcoal C. Perform immediate gastric lavage D. Insert an IV for morphine administration E. Apply a pulse oximeter
A, D, E
A nurse is caring for an infant who has biliary a treasure. Which of the following manifestations should the nurse expect? Select all that apply A. Yellow sclerae B. Rapid weight gain C. Tar colored stools D. Abdominal distention E. Dark urine
A, D, E
A nurse is assessing a nine month old infant. Which of the following findings should the nurse report to the provider as a possible developmental delay? A. Grasping a small object with just the thumb and index finger B. Dropping a cube when passing from one hand to the other C. Falling from a standing position to sitting D. Losing balance when leaning sideways while sitting
B
A nurse is caring for a child who has paralytic poliomyelitis. Which of the following actions should the nurse take? A. Implement droplet precautions B. Administer oral analgesics prior to exercises C. Use humidified oxygen to thin secretions D. Initiate seizure precautions
B
A nurse is caring for a four-year-old child who has pneumonia. The child's mother left two hours ago, and he is currently experiencing the separation anxiety stage of despair. Which of the following findings should the nurse expect? A. Crying and screaming B. Inactivity and thumb sucking C. Showing interest in nearby toys D. Attempting to escape and find the parent
B
A nurse is caring for a child who have epistaxis. Which of the following actions should the nurse take? A. Administer aspirin B. Tilt the child's head back and apply pressure C. Have the child lie down and rest D. Apply continuous pressure to the lower part of the child's nose
D
A nurse and a pediatric unit is planning care for a preschooler who will be having a surgical procedure in the morning. The child has been crying despite his parents his presence at his bedside. The nurse should add engaging the child and therapeutic play to the care plan to offer which of the following benefits? A. Decrease the child's fear of the dark B. Allow the child to manipulate toy medical equipment C. Provide an opportunity to analyze the child's emotions D. Encourage parents to engage with their child
B
A nurse is admitting a child who has acute lymphocytic leukemia. Which of the following laboratory values should the nurse expect? A. Platelets 500,000 mm^3 B. RBCs 2.5 million/uL C. WBCs 4000/mm^3 D. Hct 60%
B
A nurse is caring for a six week old infant following a pyloromyotomy. Which of the following forms of feeding should the nurse anticipate for the infant six hours after the procedure? A. Bottle formula with added protein B. Small, frequent bottle feedings of electrolyte solution C. Continuous nasoduodenal tube feedings D. Bolus feedings via gastrotomy tube
B
A nurse and a pediatric clinic is assessing a toddler at a well child visit. Which of the following actions should the nurse take? A. Performed the assessment and a head to toe sequence B. Minimize physical contact with the child initially C. Explain procedures using medical terminology D. Stop the assessment if the child becomes uncooperative
B
A nurse is planning care for a child who has hyperthermia. Which of the following actions should the nurse take? A. Administer antipyretics to the child every 4 to 6 hours B. Position the child on a cooling blanket and cover her with a sheet C. Placed a child in a tub filled with water cooled to 26.7° to 29.4°C (80° to 85°F) D. Assess the child's temperature every two hours during the cooling process
B
A nurse is providing education for a group of parents about toddler language development during a well child visit. Which of the following findings should the parent expect in an 18 month old toddler? A. Ability to refer to self by name B. Vocabulary of 10 or more words C. Following simple directional commands D. Naming a single color
B
A nurse is providing teaching for a 14-year-old client who has acne. Which of the following instruction should the nurse include? A. Use an exfoliating cleanser B. Keep hair off your forehead C. Take tetracycline after meals D. Squeeze acne lesions as they appear
B
A nurse is providing teaching to the parent of a school age child who has pediculosis. Which of the following instructions should the nurse include? A. Machine wash clothing in Coldwater B. Dry clothing in a hot dryer for at least 20 min C. Soak combs and brushes for five min in boiling water D. Seal non-washable items in a bag for seven days
B
A nurse is reviewing recommended immunizations for the guardian of a two month old infant. Which of the following statements should the nurse make? A. "Your baby can receive the varicella vaccine at six months of age" B. "Your baby can start the pneumococcal vaccine now" C. "Your baby should receive the flu vaccine before six months of age" D. "Your baby can start the measles, mumps, and rubella vaccine now"
B
A nurse is planning care for an infant who has heart failure. Which of the following interventions should the nurse include in the plan to meet the nutritional needs of the infant? Select all that apply A. Offer the infant a feeding every two hours B. Allow 30 min to complete each feeding C. Gradually increase the caloric density of the formula D. Position the infant semi-upright during feedings E. Provide gavage feeding if respiratory rate exceeds 80 per minute
B, C, D, E
A school nurse is assessing a child who has been stung by a bee. The child's hand is swelling, and the nurse notes that the child is allergic to insects things. Which of the following findings should the nurse expect if the child develops anaphylaxis? A. Bradycardia B. Nausea C. Hypertension D. Urticaria E. Stridor
B, D, E
A nurse is caring for an infant who has gastroenteritis and is dehydrated. Which of the following characteristics places the infant at a higher risk of electrolyte in balance is compared to an adult client? A. Less extracellular fluid B. Reduced body surface area C. Longer intestinal tract D. Decreased rate of metabolism
C
A charge nurse is reviewing the expected growth and development of school age children with a group of staff nurses. Which of the following statements should the nurse include? A. "A seven-year-old child prefers to play with children of a different gender" B. "A six-year-old child should understand the concept of cause-and-effect" C. "A six-year-old child should be able to count 13 coins" D. An eight-year-old child should be able to wash his or her own hair independently"
C
A nurse in an emergency department is assessing an infant who has laryngeal tracheobronchitis. Which of the following findings should the nurse report as an indication of impending airway obstruction? A. Bradycardia B. Respiratory depression C. Nasal flaring D. Barking cough
C
A nurse is assessing a school age child who reports horseback riding three times per week and has injuries reportedly related to a fall from a horse. Which of the following findings should the nurse investigate further as an indication of child maltreatment? A. Bruising of the right elbow B. Dislocated left shoulder revealed by x-ray C. Thin, frail extremities D. Abrasions on both wrists
C
A nurse is assessing a three-year-old child during well child examination. Which of the following findings should the nurse report to the provider? A. The child wets the bed when sleeping B. The child cannot catch a ball C. The child cannot walk on tiptoe D. The child builds a tower of 10 cubes
C
A nurse is creating a plan of care for an 18-month-old toddler who has cerebral palsy. Which of the following interventions should the nurse include? A. Use a mobile walker for the toddler B. Discourage activities involving repetitive joint movement C. Use manual jaw control when feeding the toddler D. Discourage the use of wrist splints
C
A nurse is planning care for a three month old infant who has an ileostomy. Which of the following interventions should the nurse include in the plan? A. Avoid laying the infant on his abdomen B. Avoid talking the appliance into the infants diaper C. Check the bag for stool every four hours D. Replace the appliance every three days
C
A nurse is planning care for an adolescent who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions should the nurse include in the plan? A. Apply cold compresses to the child's extremities B. Administer mirperidine every four hours until the crisis has resolved C. Maintain the child on bed rest D. Decrease the child's fluid intake for eight hours
C
A nurse is planning pre-operative teaching for a school age child who is scheduled for cardiac surgery. Which of the following actions should the nurse plan to take when teaching the child? A. Limit teaching sessions to 10 min B. Use simple, concrete terms when giving explanations C. Use photographs to help explain the procedure D. Conduct the teaching session 2 days before the procedure
C
A nurse is preparing to perform a routine heel puncture on a newborn. Which of the following actions should the nurse take? A. Administer tolmetin prior to the procedure B. Apply a eutectic mixture of local anesthetics (EMLA) Cream to the newborns heel after the procedure C. Prepare concentrated sucrose for oral administration D. Place the newborn in an extended position
C
A nurse is providing discharge teaching for the parent of a newborn who is prescribed a Pavlik harness for developmental dysplasia of the hip. Which of the following responses indicates an understanding of the teaching? A. I should apply powder to the folds of skin on my babies knees and thighs B. I should adjust the straps on the harness once a week as my baby grows C. I should lightly massage my baby underneath the straps once a day D. I should place my babies diaper over the straps of the harness
C
A nurse is teaching a parent of an infant who has a colostomy. Which of the following statements by the parent indicates an understanding of the teaching? A. I will not dress my child in one piece outfits B. I need to buy diapers that are tighter than those my infant usually wears C. I need to apply paste to the back of the wafer on my child's appliance D. I will not need to toilet train my child
C
A nurse is teaching about clinical manifestations of tracheomalacia to the parent of an infant who had tracheoesophageal fistula repair as a newborn. Which of the following findings should the nurse include in the teaching? A. Absence of bowel sounds B. Neck contortions C. Barking cough D. Projectile vomiting
C
A nurse is teaching the guardian of a preschooler. The guardian states that the preschooler has had an imaginary playmate for about three months. Which of the following pieces of information should the nurse give the guardian? A. "Children commonly begin having imaginary friends when they reach school-age" B. "Notify your provider if the imaginary friend persist longer than six months" C. "Have your child take responsibility for actions if he tries to blame the imaginary friend" D. "Set limits by not allowing your child to have the imaginary friend present during family meals"
C
A nurse on a pediatric oncology unit is helping the parents of a child who is terminally ill to prepare for the impending loss of their child. Which of the following statements should the nurse make? A. The nursing staff will be that your child and take care of his daily needs B. Your child will be most comfortable in a low Stimulation environment C. Would you like assistance in planning where your child will die? D. Would you like hospice to continue providing curative care in your home?
C
A nurse on a pediatric unit is reviewing to health record of a client who is demonstrating increasing levels of stress after admission. The nurse should identify which of the following findings as a risk factor for a stress related reaction to hospitalization? A. Age 10 years B. First hospitalization C. Male gender D. Calm, quiet demeanor
C
The nurse is planning care for an infant with an unrepaired myelomeningocele. Which of the following actions should the nurse take? A. Fasten the diaper loosely B. Cleanse the meningeal sac with povidone iodine daily C. Palpate the abdomen for bladder distention D. Cover the sack with a dry, sterile gauze dressing
C
The nurse on a pediatric unit is caring for a group of clients. Which of the following findings should be the nurse's priority? A. A child who has asthma and a pulse oximetry of 94% B. A child who has nephrotic syndrome and 1+ protein on urine dipstick C. A child who has sickle cell anemia and a urine specific gravity of 1.030 D. A child who has insulin-dependent diabetes mellitus and a fingerstick glucose reading of 110 mg/dL
C
A nurse is caring for a school age child who has skeletal traction applied to repair a pelvic fracture. Which of the following actions should the nurse take? A. Russ the child's traction weights on the floor for eight hours during the night B. Ensure the child's meal tray contains no high fiber foods C. Perform passive range of motion exercises on the child involved joints every four hours D. Place the child on a pressure reduction mattress
D
A nurse is caring for a toddler. Which of the following objects should the nurse select from the playroom for this child during hospitalization? A. Small plastic doll with clothes and accessories B. Alphabet flashcards C. Handheld video game D. 10 piece wooden puzzle
D
A nurse is caring for an adolescent client who has a prescription for opioids. Which of the following findings should the nurse recognize as an adverse effect of opioids? A. Dilated pupils B. Tremors C. Yawning D. Pruritus
D
A nurse is caring for an infant who has pertussis. Which of the following actions should the nurse take? A. Assess for edema of the extremities B. Apply warm compresses to the neck area C. Initiate airborne precautions D. Maintain a cardiorespiratory monitor
D
A nurse is creating a plan of care for six month old infant who requires continuous pulse oximetry monitoring. Which of the following interventions should the nurse include? A. Reposition the sensor to a new site once every 24 hours B. Secure the oximetry sensor to the infant's wrist C. Apply conduction gel to the skin before attaching the sensor D. Cover the oximetry sensor with clothing
D
A nurse is planning to implement relaxation strategies with a young child prior to a painful procedure. Which of the following actions should the nurse take? A. Ask the child to hold a breath and blow it out slowly B. Ask the child to describe a pleasurable event C. Bounce the child gently while holding him upright D. Rock the child using long, rhythmic movements
D
A nurse is planning to use guided imagery for an early school age child who continues to have mild discomfort following the administration of an analgesic. Which of the following techniques should the nurse plan to use? A. Give the child a kaleidoscope and ask the child to find different designs B. Encourage the child to take a deep breath and let the body go limp on the exhale C. Teach the child to picture a stop sign whenever the pain begins D. Encourage the child to focus on a recent pleasurable experience
D
A nurse is preparing to administer an enema to a 10 month old infant. Which of the following actions should the nurse plan to take? A. Administer the enema using room temperature tapwater B. Insert this tubing 7.5 cm (3 in) into the rectum C. Position in the infant sitting upright on a bed pan while administering the enema D. Hold the infants buttocks together after administering the fluid
D
A nurse is providing discharge teaching to the parents of a child who has nephrotic syndrome. Which of the following instructions should the nurse include in the teaching? A. Restrict the child's potassium intake B. Administer acetaminophen to the child twice daily C. Weigh the child wants each week D. Keep the child away from people who have an infection
D
A nurse is providing teaching to a 12-year-old client who is recovering from an acute episode of hemophilia a. Which of the following statements should the nurse include in the teaching? A. Have your parents stretch and move your legs for you B. Apply heat to joints that become painful, stiff, and swollen C. Take aspirin at the first sign of a headache D. You will be able to participate in physical exercises
D
A nurse is reviewing laboratory findings of an adolescent who has acute renal failure. Which of the following findings should the nurse expect? A. Hypokalemia B. Hypercalcemia C. Decreased plasma creatinine level D. Metabolic acidosis
D
A nurse is teaching an adolescent about various strategies for chronic pain management. Which of the following activities should the nurse use as an example of the non-Pharma logical strategy of thought stopping? A. Assemble a puzzle B. Discuss a recent pleasurable event C. Tighten and then relax each body part D. Repeat memorized facts about the painful event
D
A nurse is assessing a child who is receiving IV chemotherapy. Assessment findings include extra vacation of the tissue surrounding the IV insertion site. In which order should the nurse take the following actions? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Stop the infusion Elevate the extremity Notify the provider Remove the IV line
A nurse is assessing a four-year-old child. The nurse should expect the child to be able to perform which of the following activities? A. Fastening buttons on a shirt B. Tying shoelaces C. Parting and combing hair D. Cutting the meat at dinner
A
A nurse is assessing a six month old infant who had a cardiac catheterization with right femoral entry to diagnose a possible congenital heart defect. Which of the following findings should the nurse report to the provider? A. Cool toes on the right foot B. Weak pedal pulses on both feet C. Positive Babinski reflex on both feet D. Erythema on the right foot
A
A nurse is assessing a two month old infant who has a ventricular septal defect. Which of the following findings should the nurse report to the provider? A. Weight gain of 1.8 kg (4 lb) B. Heart rate of 125 bpm C. Soft, flat fontanel D. Systemic murmur
A
A nurse is assessing an infant who develops in respiratory distress, absence of breath sounds on one side, and deviation of the trachea away from the affected side. Based on these manifestations, which of the following conditions is the infant experiencing? A. Tension pneumothorax B. Flail chest C. Pulmonary contusion D. Fractured rib
A
A nurse is caring for a child who has bacterial endocarditis. The child is a scheduled to receive moderate term antibiotic therapy and requires a peripherally inserted central catheter (PICC). Which of the following statements should the nurse include when teaching the child's parent? A. The PICC line will last for several weeks with proper care B. The public health nurse will rotate the insertion site every three days C. You will need to ensure the arm board is in place at all times D. Your child will go to the operating room to have the line placed
A
A nurse is caring for a female adolescent who is being treated for frequent urinary tract infection (UTIs). Which of the following statements by the adolescent indicates a possible cause of the UTIs? A. I have bowel movements every 4 to 5 days B. My mom taught me to wipe from front to back after going to the bathroom C. I urinate every 2 to 3 hours during the day D. I don't wear nylon underwear
A
A nurse is caring for a preschooler who has a terminal illness. The nurse should expect the preschooler to have which of the following perspectives about death? A. Believes that her own thoughts can cause death B. Has an understanding of the finality of death C. Exhibits curiosity about what happens to the body after death D. Views funeral services as unnecessary
A
A nurse is caring for an infant who is experiencing dehydration. Which of the following assessment is the nurses priority? A. Measure the clients daily weight B. Check for tears C. Palpate the fontanel D. Assess skin turgor
A
A nurse is performing a physical assessment on a 12 month old infant. which of the following should the nurse report to the provider? A. The infants current weight is doubled his birth weight B. The infant's posterior fontanel is closed C. The infant is unable to walk without support D. A total of six teeth are present
A
A nurse is preparing a school age child for a tonsillectomy. Which of the following actions should the nurse take? A. Schedule the child for a pre-operative visit to the facility B. Inform the child he will be put to sleep for the procedure C. Read the child a story about a cartoon character having a similar operation D. Tell the child the appointment is to have his throat checked
A
A nurse is preparing to assess a three month old infant during a well child visit. Which of the following observations should the nurse expect? A. The infant looks at his hands B. The infant has a pincer grasp C. The infant has no head lag when pulled to a sitting position D. The infant can independently roll from his back to his abdomen
A
A nurse is providing dietary teaching to the parent of a child who has cystic fibrosis. Which of the following dietary recommendations should the nurse make? A. Increase the child's protein intake B. Decrease the child's calorie intake C. Increase the child fiber intake D. Decrease the child salt intake
A
A nurse is providing teaching to the parents of a child who has strabismus. Which of the following instructions should the nurse include to prevent the development of amblyopia? A. Patch the unaffected Eye B. Administer Mydriatic eyedrops daily C. Obtain prescription eyeglasses D. Administer anti-histamines
A
A nurse is providing teaching to the parents of a four-year-old child about fine motor development. Which of the following task should the nurse include as an expected finding for this age group? A. Copying a circle B. Cutting foods using a table knife C. Beginning to write in cursive D. Printing the first and last name clearly
A
A nurse is teaching a group of parents of toddlers about measures to reduce the risk of choking. Which of the following foods increase the risk of choking in toddlers? Select all that apply A. Hot dogs B. Grapes C. Bagels D. Marshmallows E. Graham crackers
A, B, C, D
A nurse is caring for an adolescent who has sickle cell anemia. Which of the following manifestations is/are the result of chronic vaso-occlusive pneumonia? (Select all that apply) A. Enlarged heart B. Enuresis C. Leg ulcers D. Extrahepatic cholestasis E. Retinal detachment
A, B, C, E
A nurse is admitting a client who has derealization disorder. Which of the following manifestation should the nurse expect? A. The inability to recall important personal information B. The feeling that the surroundings are unreal C. The inability to recall identity D. The presence of at least two distinct personalities
B
A nurse is assessing a 6 month old infant. The Guardian reports that the infant does not appear interested in the brightly colored mobile hanging above the crib at home. Which of the following techniques should the nurse use to check the infants visual acuity? A. Shine a penlight briefly into the left eye and then the right eye B. Move a brightly colored toy from side to side in front of the infants face C. Ask the guardian to sit in front of the infant and not his head up and down D. Observe the infants ability to grasp the feet and pull them to the mouth
B
A nurse is assessing a four-year-old child cognitive development during a well child visit. Which of the following should the nurse expect the child to display? A. Conservation B. Development of the super ego C. Concrete operational thought D. Separation anxiety
B
A nurse is assessing the visual acuity of a group of school age children. Which of the following actions should the nurse take? A. Position each child with their heels at a line that is 6 m (20 ft) away from the Snellen chart B. Allow each child to wear his or her glasses during the exam C. Start the screening by covering each child's right eye D. Begin by having each child read the largest line of letters at the top of the Snellen chart
B
A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions should the nurse take? A. Maintain the child on strict bed rest B. Check the child's blood pressure every four hours C. Administer albumin to the child every eight hours D. Provide the child with a low carbohydrate diet
B
A nurse is caring for a child who has an exacerbation of cystic fibrosis. Which of the following laboratory findings should the nurse report to the provider immediately? A. Blood glucose 140 mg/dL B. Oxygen saturation 85% C. RBC 3.2 million/uL D. Serum sodium 156 mEq/L
B
A nurse is caring for a four week old infant who is two weeks post operative following surgical correction of biliary atresia. Which of the following findings is an indication that the surgery was successful? A. The infant has lost 2.2 kg (1lb) since the surgery B. The infant has a total bilirubin level of 0.3 mg/dL C. The infant has an aspirate aminotransferase (AST) level of 120 units/L D. The infant stools are gray in color
B
A nurse is caring for a preschool age child who has mucosal ulceration after receiving chemotherapy. Which of the following actions should the nurse take? A. Place viscous lidocaine on the child's oral lesions B. Instruct the child to use a soft sponge toothbrush when brushing her teeth C. Encourage the child to rinse her mouth with hydrogen peroxide every 2 to 4 hours D. Give the child lemon glycerin swabs to use after each meal
B
A nurse is planning care for a preschooler who is immediately postoperative following the placement of a ventriculoperitoneal shunt. Which of the following interventions should the nurse include in the plan? A. Monitor the preschoolers pupils every eight hours B. Lay the preschooler on the non-operative side C. Keep the head of the bed elevated to 30° D. Check bowel sounds once per day
B
A nurse is providing teaching about disease management to the parent of a preschooler who has a new diagnosis of asthma. Which of the following parent statements indicates an understanding of the teaching? A. My child should not receive live virus vaccines B. I will encourage my child to participate in sports C. I will give my child aspirin when she has a fever D. My child will outgrow asthma by adulthood
B
A nurse is teaching the parent of a child who has type one diabetes mellitus how to manage the child's disorder during illness such as a cold. Which of the following statements by the parent indicates an understanding of the teaching? A. I'll reduce my child food intake B. I'll check his blood glucose more often C. I'll limit his fluid intake between meals D. I won't administer his long acting insulin dose
B
A nurse is conducting a health assessment for a 24 month old toddler at the local health department. The nurse should expect which of the following findings? (Select all that apply) A. Eight deciduous teeth B. Ability to build a tower of six blocks C. Vocabulary of 10 to 20 words D. Slightly bowed or curved leg appearance E. Head circumference greater than chest circumference
B, D
A charge nurse is providing education about child maltreatment to a group of newly licensed nurses. Which of the following pieces of information should discharge nurse include in the teaching? A. Preschoolers have the highest rates of maltreatment B. In single parent families, the parents non-biological partner is typically the abuser of the child C. Children who were born prematurely are more likely to be maltreated D. Child maltreatment occurs equally across all socioeconomic groups
C
A nurse in the emergency department is in admitting a child who has full thickness burns over 45% of his body. Which of the following actions should the nurse take first? A. Administer IV morphine B. Administer topical anti-microbials C. Administer IV fluid replacement D. Administer tetanus prophylaxis
C
A nurse is admitting a child who has Wilms tumor. Which of the following actions should the nurse take? A. Initiate contact precautions for the child B. Explain to the child's parents that chemo therapy will start three months after surgery C. Put a "no abdominal palpation" sign over the child's bed D. Prepare the child for a spinal tap
C
A nurse is assessing a 24 month old toddler who has a new diagnosis of autism spectrum disorder (ASD). Which of the following findings should the nurse expect? A. Wanting to be held frequently B. Ability to build a tower of 10 cubes C. Impaired language skills D. Ability to stand one foot
C
A nurse is assessing a 30 month old toddler during a well child visit. Which of the following findings requires further assessment by the nurse? A. Primary dentition is complete B. The toddler is unable to hop on 1 foot C. The toddler's birth way is tripled D. The toddler is able to state her first and last name
C
A nurse is assessing a newborn at birth to assign Apgar scores. At 1 min of age, the newborn is crying vigorously with limbs flexed and has a heart rate of 120 bpm. the newborn's trunk is pink, but his hands and feet are cyanotic, and he cries when the soles of his feet are stimulated. which of the following Apgar scores should the nurse assign this infant? A. 7 B. 8 C. 9 D. 10
C
A nurse is assessing a seven-year-old child's psychosocial development. Which of the following findings should the nurse recognize as an indicator for further evaluation? A. The child prefers playmates of the same sex B. The child is competitive when playing board games C. The child complains daily about going to school D. The child enjoys spending time alone
C
A nurse is caring for a child who has glomerulonephritis. Which of the following actions should the nurse take? A. Monitor the child's blood pressure twice per day B. Maintain the child on bed rest for three days C. Weigh the child once each day D. Increase the child's daily intake of sodium
C
A nurse is caring for a four month old child who has acute otitis media and a fever of 38.3°C (101°F). Which of the following medications should the nurse administer? A. Diphenhydramine B. Furosemide C. Amoxicillin D. Ibuprofen
C
A nurse is caring for a one year old infant who has chronic otitis media. The nurse should identify that which of the following areas is at risk of a delay in development? A. Fine motor skills B. Visual acuity C. Speech patterns D. Hand to eye coordination
C
A nurse is caring for a school age child who has an arm cast applied eight hours ago. Which of the following findings should alert the nurse to a complication related to the casting? A. The child reports a pain level of five on a scale of 0 to 10 B. The child's hands are cool bilaterally C. The child reports tightness at the wrist D. The child's grasp is weak
C
A nurse is caring for a toddler. Which of the following laboratory findings should the nurse report to the provider? A. BUN 8 mg/dL B. Uric acid 3.0 mg/dL C. Creatinine 0.9 mg/dL D. Urine specific gravity 1.010
C
A nurse is caring for six month old infant who has intussusception. Which of the following actions should the nurse take? A. Prepare to administer high-dose steroids B. Give the child magnesium hydroxide PO C. Prepare the child for a barium enema D. Inform the parents that the child will need a colostomy
C
A nurse is preparing to administer recommended immunizations to a two month old infant. Which of the following immunization should the nurse plan to administer? A. Human papillomavirus (HPV) and hepatitis A B. Measles, mumps, and rubella (MMR) and tetanus, diphtheria, and acellular pertussis (DTaP) C. Haemophilus influenzae type B (Hib) and in activated polio virus (IPV) D. Varicella (VAR) and live attenuated influenza vaccine (LAIV)
C
A nurse is providing anticipatory guidance about the accidental ingestion of a toxic substance to the parents of a toddler. The nurse should instruct the parents to take which of the following actions first if the child ingests a hazardous substance? A. Give the toddler milk B. Go to an emergency department C. Call the poison control center D. Induce vomiting
C
A nurse is providing teaching about poisoning prevention to a group of parents with toddlers. Which of the following statements should the nurse make? A. Keep medications on a counter that is out of reach of the toddler B. Do not keep live plants in the house C. Put all cleaning supplies in a locked cabinet D. Allow your child to eat from his or her favorite ceramic bowls
C
A nurse is providing teaching to the parent of a toddler who has bacterial conjunctivitis. Which of the following instruction should the nurse include? A. Clean secretions from the infected I by wiping from the outer canthus towards the inner canthus and upward B. Keep the infected I covered with warm compresses for the first 24 to 48 hours C. Notify the provider immediately if the sclera becomes inflamed D. Apply pressure to the outer canthus of the eye for one minute after administering the eyedrops
C
A nurse is receiving the laboratory reports of a child with acute nephrotic syndrome who has been receiving prednisone by mouth for the past week. Which of the following findings should the nurse report to the provider? A. Serum sodium 142 mEq/L B. Serum potassium 4 mEq/L C. WBC count 3,000/mm^3 D. Platelet count 298,000/mm^3
C
A nurse is reviewing the laboratory values for a six month old infant who has acute renal failure. Which of the following findings should the nurse expect? A. BUN 5 mg/dL B. Creatinine 0.2 mg/dL C. Sodium 125 mEq/L D. Potassium 4.2 mEq/L
C
A nurse is teaching the parent of an infant about home safety. Which of the following pieces of information that should the nurse include? (select all that apply) A. Use a wheeled infant walker B. Place soft pillows around the edge of the infants crib C. Position the car seat so it is rear facing D. Secure a safety gate at the top and bottom of the stairs E. Maintain the water heater temperature at 49°C (120°F)
C, D, E
A nurse and an emergency department is caring for an eight-year-old who is up-to-date with current immunization recommendations and has a deep puncture injury. Which of the following should the nurse anticipate administering? A. Diphtheria, tetanus, and acellular pertussis (DTaP) vaccine B. Single injection of tennis immune globulin (TIG) mixed with pediatric tetanus booster (DT) C. Tetanus, diphtheria, and acellular pertussis (Tdap) vaccine D. Adult tetanus booster (Td)
D
A nurse is caring for a child who has suspectEd nephrotic syndrome. Which of the following laboratory values should the nurse expect? A. Platelets 120,000/mm^3 B. Serum sodium 160 mEq/L C. Hgb 9 g/dL D. Serum cholesterol 700 mg/dL
D
A nurse is caring for a child who has tetralogy of Fallot. Which of the following laboratory values should the nurse expect to find? A. Platelet count of 20,000/mm^3 B. WBC 4000/mm^3 C. Thyroid stimulating hormone 7.0 microunits/mL D. RBC 6.8 million/uL
D
A nurse is caring for a child with cystic fibrosis who has a pulmonary infection. Which of the following findings is the nurses priority? A. Blood streaking of the sputum B. Dry mucous membranes C. Constipation D. Inability to clear secretions
D
A nurse is caring for a school age child who has hemophilia and fell on the playground. The child reports a pain level of four on a scale of 0 to 10. Which of the following actions should the nurse take? A. Administer an NSAID B. Perform passive range of motion exercises on the joint C. Administer cryoprecipitate D. Apply an ice pack to the joint
D
A nurse is providing teaching to the parent of a child who has ADHD and a new prescription for methylphenidate sustained-release tablets. Which of the following statements by the parent indicates an understanding of the teaching? A. I should expect my child to gain weight while taking this medication B. I should expect this medication to decrease my child's heart rate C. I should crush the medication and put it in my child's food D. I should give this medication to my child half an hour before breakfast
D
A nurse is admitting a child who has a urinary tract infection (UTI) and a history of myelomeningocele. After completing the admission history, which of the following actions should the nurse plan to take? A. Attach a latex allergy alert identification band B. Initiate contact precautions C. Post signs in the clients bathroom to strain the clients urine D. Administer folic acid with meals
A
A nurse teaching the parent of a three-year-old toddler about promoting sleep. Which of the following pieces of information should the nurse include? A. Following nightly routine is establish bedtime B. encourage active play prior to bedtime C. Let the child remain awake until tired enough to sleep D. Reward the child with a food treat just before sleep if the child goes to bed on time
A
A nurse is developing a plan of care for a school age child who underwent a surgical procedure that resulted in a temporary loss of vision. Which of the following interventions should the nurse include in the plan of care? A. Assign an assistive personnel to feed the child B. Explain the sounds the child is hearing C. Have the child use a cane when ambulating D. Rotate nurse is caring for the child
B
A nurse is discussing disciplinary techniques with the guardian of a preschooler. Which of the following actions indicates to the nurse at the guardian is using an age-appropriate disciplinary technique? A. The guardian explains to the child why her behavior is unacceptable B. The guardian place is the child in time out after misbehaving C. The guardian allows the child to choose the consequence of her misbehavior D. The guardian assigned an extra chore for the child's misbehavior
B
A nurse is observing the behavior of a two-year-old child. Which of the following actions should the nurse expect to observe when the child is in an activity room with other toddlers? A. Playing a simple game with another child B. Engaging in play near other children C. Sharing crayons with another toddler D. Jumping on 1 foot without help
B
A nurse is assessing a toddler who has gastroenteritis. Which of the following findings indicates the toddler is experiencing severe dehydration? A. Slight thirst B. Capillary refill of three seconds C. Deep, rapid respirations D. Decreased tear production
C
A nurse is assessing a 10-month-old infant at a well infant check up. Which of the following assessment findings should the nurse report to the provider? A. The infant is unable to walk independently B. The infants Moro reflex is absent C. The infants anterior fontanel is open D. The infant needs assistance to sit up
D
A nurse is caring for a 12 month old infant following the surgical repair of a cleft palette. The nurse should plan to feed the infant using which of the following instruments? A. Spoon B. Straw C. Firm nipple D. Cup
D
A nurse working on a maternal newborn unit is teaching a group of newly licensed nurses about assisting new mothers with breast-feeding. The nurse should include which of the following infant conditions as a contraindication for breast-feeding? A. Galactosemia B. Hyperbilirubinemia C. Glycogen storage disease D. Hypothyroidism
A
A nurse is providing teaching to the guardian of a child who has Kawasaki disease. Which of the following statements by the guardian indicates an understanding of the teaching? (Select all that apply) A. My child will likely be irritable for the next few weeks B. I will notify my child's doctor if the skin on her hands or feet begins to peel C. I will ensure my child does not receive any live vaccines for at least 18 months D. I will keep a record of my child's temperature until she has no fever for several days E. My child will have joint stiffness primarily at the end of the day
A, C, D
A nurse on a pediatric unit is caring for a preschooler who is prescribed an IV medication. Which of the following actions should the nurse take to prepare the child for the procedure? A. Use role-play activities with the child B. Provide the child with a detailed explanation of the procedure C. Implement interactive sessions of 30 minutes each with the child D. Give the child identical IV supplies to play with
A
The nurse is discussing the causes of chronic diarrhea with the client. Which of the following conditions is caused by malabsorption? A. Celiac disease B. Ulcerative colitis C. Hirschsprung's disease D. Crohn's disease
A
A nurse is providing teaching to a parent of a preschooler who has tinea capitis. Which of the following instructions should the nurse include in the teaching? A. Apply aluminum acetate solution compresses to the lesions B. Apply Hydro Cortizone cream to the lesions twice daily C. Seal non-washable toys in a plastic bag for two weeks D. Leave the medicated shampoo on the scout for 5 to 10 minutes
D
A nurse is performing a well child assessment on a four-year-old child. Which of the following findings should the nurse expect? A. The child is able to hop on 1 foot B. The child is able to build a tower of up to six blocks C. The child is able to name the days of the week D. The child is able to identify left and right
A
A nurse is teaching the parent of an infant about injury prevention. Which of the following statements by the parent indicates an understanding of the teaching? A. I should lightly shake talcum powder on my babies skin after each diaper change B. I should use a drop side crib after my baby is six months old C. I should make sure my babies clothing does not have buttons D. I should ensure the crib slats are no more than 3 inches apart
C
A nurse on a pediatric unit is caring for a child who is not eating well. Which of the following suggestions should the nurse offered to the parents to promote the child's food and take? A. Make dietary selections for your child B. Offer foods that have strong flavors or smells C. Let your child eat with others when possible D. Make sure your child eats most of the food on his plate
C
A nurse is preparing to obtain an antistreptolysin O (ASO) titer from a child who has acute glomerulonephritis. The child's parents ask the nurse to explain the purpose of the test. Which of the following responses should the nurse provide? A. This test determine the level of antibiotics in your child's blood B. The test tells us if your child ever had measles C. The test verifies the amount of albumin in your child's blood D. The test shows us if your child had a recent strep infection
D
A nurse is providing anticipatory nutritional guidance for the caregivers of a five month old infant. Which of the following points should the nurse include in the teaching? A. Switch the infant from formula to low fat cows milk at six months of age B. Heat fruit juice before offering it to the infant C. Introduce a new food every other day D. Allow the infant to try finger foods, such as crackers, after six months of age
D
A nurse is providing teaching to the parent of an infant who has developmental hip dysplasia any new prescription for a Pavlik harness. Which of the following parent statements indicates an understanding of the teaching? A. I will apply the harness over a T-shirt and kneesocks B. I will put my babies diaper over the harness C. I will make the required harness adjustments as my baby grows D. I will apply powder around the harness buckles each day
A
A nurse is teaching the parent of a preschool age child about the treatment for pinworms. Which of the following statements by the parent indicates an understanding of the teaching? A. I will give my child a dose of albendazole today and again in two weeks B. I will collect specimens immediately after my child has a bowel movement C. I will give my child a tub bath twice each day D. I will place my child's bed linens in a sealed plastic bag for seven days
A
A nurse is caring for a preschooler who is brought to an outpatient clinic with a two day history of a vesicular, honey colored crusty region around the nose and mouth. If the provider determines the lesions to be impetigo contagiosa, what should the nurse anticipate get teaching the child's parent about the illness? (select all that apply) A. Apply a topical anti-bacterial ointment to the lesions B. Wash the child bed linens daily with hot water C. Administer a sick Lavere oral suspension to prevent recurrence D. Allow the crust covering the infected lesions to remain intact E. Wash hands before and after contact with the affected area
A, B, E
A nurse is assessing an adolescent who has appendicitis. Which of the following manifestations should the nurse expect? A. Upper right quadrant abdominal pain B. Rigid abdomen C. Hyperactive bowel sounds D. Bradycardia
B
A nurse is caring for a child who has been in Buck's traction for two days. Which of the following actions should the nurse take to prevent complications? A. Manually move the weights to the floor when the child is experiencing pain B. Check for pulses in the affected lake every four hours C. Cleanse the pins every 12 hours D. Inform parents to discourage visitors for the child
B
A nurse is teaching the parents of a 10-year-old child who has iron deficiency anemia. Which of the following statements by a parent indicates an understanding of the teaching? A. I will give my child an iron tablet once each day at bedtime B. I will administer the iron tablet with orange juice C. I will encourage my child to take an antacid with the iron tablet D. I will crush the iron tablet prior to giving it to my child
B
A nurse is providing teaching to the guardians of a four month old infant on how to play with the infant. Which of the following play activities should the nurse suggest for this infant? A. Show the infant a board book with large pictures B. Imitate the sound of different farm animals for the infant C. Give the infant a large push pull toy D. Allow the infant to splash in the bathtub
D
A nurse is teaching a parent of a 12 month old infant about development during the toddler years. Which of the following statements should the nurse include? A. Your child should be referring to himself using the appropriate pronoun by 18 months of age B. A toddler first shows interest in looking at pictures at 20 months of age C. A toddler should have daytime control of his bowels and bladder by 24 months of age D. Your child should be able to scribble spontaneously using a crayon at 15 months of age
D
A nurse is teaching to a group of parents of adolescents about developmental needs. Which of the following statements by a parent should The nurse investigate further? A. My child has frequent mood swings B. My child has a very messy bedroom C. My child takes one to two showers per day D. My child spends four hours per day using online chat rooms
D
A nurse is providing teaching to an adolescent who was recently diagnosed with type one diabetes mellitus. Which of the following insulin injection sites should the nurse recommend that the client used during basketball competitions? A. Hip B. Upper arm C. Thigh D. Lower leg
A
A nurse is planning care for a child who has meningococcal meningitis. Which of the following isolation precautions should the nurse plan to implement? A. Airborne precautions B. Contact precautions C. Protective environment D. Droplet precautions
D
A nurse is providing teaching to the parents of an infant who is breast-feeding. When should the nurse instructed parents to introduce solid foods in the infants diet? A. After the rooting reflex disappears B. At 2 to 3 months of age C. After the infants first tooth erupts D. At 4 to 6 months of age
D
A nurse is assessing a six month old infant who was recently admitted with acute vomiting and diarrhea. Which of the following findings indicates the infant has moderate dehydration? A. Bulging anterior fontanel B. Bradycardia C. Tachypnea D. Polyuria
C
A nurse is teaching the guardian of an 18 month old toddler about otic medication administration. Which of the following statements should the nurse make? A. " administer the drops immediately after removing the medication from the refrigerator" B. "Place the child in a seated position with the head tilted to the side for administration" C. " gently pull the ear cartilage down and back when administering the medication" D. " position the medication bottle so the drops do not touch the side of the ear canal"
C
A nurse is assessing a nine month old infant during a well child visit. Which of the following findings indicates that the infant has a developmental delay? A. Creeping on hands and knees B. Inability to vocalize vowel sounds C. Using a crude pincer grasp D. Standing by holding onto a support
B
A nurse is assessing a six-year-old child who began treatment for pneumococcal pneumonia four days ago. Which of the following findings should the nurse identify as an indication the treatment is effective? A. Dullness with chess percussion B. Heart rate 118 bpm C. Conjunctival discharge D. Respiratory rate 28/min
B
A nurse is caring for an adolescent following a lumbar puncture. Which of the following actions should the nurse take? A. Initiate NPO status for the adolescent B. Place the adolescent in a supine position C. Place a moist warm pack on the adolescents lower back D. Apply a eutectic mixture of local anesthetics (EMLA) to the adolescents puncture site
B
During a well child visit, the guardian of a toddler reports that the toddler take several hours to fall asleep at night. Which of the following recommendations should the nurse to make? A. Vary the time the toddler goes to bed each night B. Allow the toddler to watch television before bedtime C. Provide the toddler with a favorite stuffed animal at bedtime D. Increase the toddlers activity prior to bedtime
C
A nurse is caring for an infant who is six months old and has moderate dehydration. Which of the following findings should the nurse expect? A. Absent tears B. Weight loss less than 10% C. Lethargy D. Dry mucous membranes
D
A nurse is providing teaching to the parent of a two-year-old toddler about nutrition. Which of the following statements by the parent indicates an understanding of the teaching? A. My child should consume 1000 cal per day B. My child should have 4 ounces of protein per day C. I should give my child 32 ounces (4 cups) of milk per day D. I should feed my child 4 ounces (1/2 cup) Of vegetables per day
A
A nurse is caring for a seven-year-old child who is in skeletal traction following a complete fracture of the femur. Which of the following diversion or activity should the nurse offer to the child? A. Puzzle with large pieces B. Building blocks C. Finger paints D. Chapter books
D
A nurse is caring for a toddler who has a fever, a high-pitched cry, irritability, and vomiting. Which of the following actions should the nurse take? A. Administer 81 mg of aspirin to the toddler B. Give the toddler a cold bath C. Place the toddler in a supine position D. Pad the rails of the toddler's bed
D
A nurse at a pediatric clinic is assessing a five month old infant during a well child visit. Which of the following findings should the nurse report to the provider? A. Head lagging when the infant is polled from a lying to a sitting position B. Absence of startle and crawl reflexes C. Inability to pick up a rattle after dropping it D. Rolling from back to side
A
