Milestones
When does an infant start smiling?
2-3 months
A nurse is preparing to care for a 5-year-old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing that which of the following is the most appropriate activity for this child?
1. Large picture books
2. A radio
3. Crayons and coloring book
4. A sports video
3. Crayons and coloring book
A 1-day-old neonate, 32 weeks' gestation, is in an overhead warmer. The nurse assesses the morning axillary temperature as 96.9°F. Which of the following could explain this assessment finding?
1. This is a normal temperature for a preterm neonate.
2. Axillary temperatures are not valid for preterm babies.
3. The supply of brown adipose tissue is incomplete.
4. Conduction heat loss is pronounced in the baby.
3. The supply of brown adipose tissue is incomplete
A 5-year-old child is receiving morphine sulfate for pain. Which statement by the caregiver indicates that further teaching is necessary?
1. "I will call the nurse if my child begins to act aggressively."
2. "I'm concerned that my child thinks the pain is punishment."
3. "My child is playing and so does not need pain medication."
4. "The FACES pain scale seems to be working very well."
3. "My child is playing and so does not need pain medication."
A parent of a 3-year-old tells a clinic nurse that the child is rebelling constantly and having temper tantrums. Using Erikson's psychosocial development theory, which instructions should the nurse provide to the parent? Select all that apply.
1. Set limits on the child’s behavior.
2. Ignore the child when this behavior occurs.
3. Allow the behavior because this is normal at this age period.
4. Provide a simple explanation of why the behavior is unacceptable.
5. Punish the child every time the child says” no” to change the behavior.
1. Set limits on the child's behavior
4. Provide a simple explanation of why the behavior is unacceptable
At what age can an infant begin eating solid foods?
6 months
An adolescent girl tells the nurse that she is very suicidal. The nurse asks her if she has a specific plan. Asking this should be considered:
1. An appropriate part of the assessment.
2. Not a critical part of the assessment.
3. Suggesting that the adolescent needs a
plan.
4. Encouraging the adolescent to devise a
plan.
1. An appropriate part of the assessment
A baby is grunting in the neonatal nursery. Which of the following actions by the nurse is appropriate?
1. Place a pacifier in the baby's mouth.
2. Check the baby's diaper.
3. Have the mother feed the baby.
4. Assess the respiratory rate.
4. Assess the respiratory rate
The nurse in the pediatric clinic is reviewing the list of clients on the appointment schedule for the day. Which client should the nurse identify as being at the highest risk for developing Reye syndrome?
1. A 10-year-old client scheduled for a follow-up visit for the treatment of strep throat
2. An 8-month-old infant with varicella-zoster not responding to treatment with famciclovir
3. A 2-year-old client with a fever of 101.3℉ (38.5℃) who is not responding to the treatment for tonsillitis
4. A 5-year-old client whose parents have been treating his fever with aspirin
4. A 5-year-old client whose parents have been treating his fever with aspirin
The mother of an 8-year-old child tells the clinic nurse that she is concerned about the child because the child seems to be more attentive to friends than anything else. Using Erikson's psychosocial development theory, the nurse should make which response?
1. You need to be concerned.
2. You need to monitor the child’s behavior closely.
3. At this age the child is developing his own personality.
4. You need to provide more praise to the child to stop this behavior.
3. At this age the child is developing his own personality.
By what age should an infant be able to pull itself up to standing?
9 months
The parent of a 4-year-old son tells the nurse that the child believes "monsters and boogeyman" are in his bedroom at night. The nurse's best suggestion for coping with this problem is to:
1. Insist that the child sleep with his parents
until the fearful phase passes.
2. Suggest involving the child to find a
practical solution such as a night light.
3. Help the child understand that these fears
are illogical.
4. Tell the child frequently that monsters and
boogeyman do not exist.
2. Suggest involving the child to find a
practical solution such as a night light.
A neonate is under phototherapy for elevated bilirubin levels. The baby's stools are now loose and green. Which of the following actions should the nurse take at this time?
1. Discontinue the phototherapy.
2. Notify the health care practitioner.
3. Take the baby's temperature.
4. Assess the baby's skin integrity.
4. Assess the baby's skin integrity
The parents of a 4-year-old child with cerebral palsy have brought him in for a routine physical exam. The parents ask the nurse about vaccinations for their child and if the child should get the annual flu shot. Which response from the nurse is correct?
1. He should get the flu shot because he can have worse symptoms from influenza compared to other children
2. He should get the flu shot because there is a chance of death from influenza infection
3. He should not get the flu shot because he is at too high risk from his medical condition
4. You should avoid giving him the flu shot. Instead, keep him indoors and practice good hand hygiene
1. He should get the flu shot because he can have worse symptoms from influenza compared to other children
Which stage of development is most unstable and challenging regarding development of personal identity?
1. Adolescence
2. Toddler hood
3. Childhood
4. Infancy
1. Adolescence
By what age should an infant have doubled it's birth weight?
6 months
A 16-year-old is admitted to the hospital for acute appendicitis, and an appendectomy is performed. Which of the following nursing interventions is most appropriate to facilitate normal growth and development?
1. Allow the family to bring in the child's favorite computer games
2. Encourage the parents to room-in with the child
3. Encourage the child to rest and read
4. Allow the child to participate in activities with other individuals in the same age group when the condition permits
4. Allow the child to participate in activities with other individuals in the same age group when the condition permits
A 42-week-gestation baby has been admitted to the neonatal intensive care unit. At delivery, thick green amniotic fluid was noted. Which of the following actions by the nurse is critical at this time?
1. Bath to remove meconium-contaminated fluid from the skin.
2. Ophthalmic assessment to check for conjunctival irritation.
3. Rectal temperature to assess for septic hyperthermia.
4. Respiratory evaluation to monitor for respiratory distress.
4. Respiratory evaluation to monitor for respiratory distress.
A child with severe cerebral palsy is admitted to the hospital with aspiration pneumo- nia. What is the most beneficial educational information that the nurse can provide to the parents?
1. The signs and symptoms of aspiration pneumonia.
2. The treatment plan for aspiration pneumonia.
3. The risks associated with recurrent aspiration pneumonia.
4. The prevention of aspiration pneumonia.
4. The prevention of aspiration pneumonia.
Most infants begin to fear strangers at age:
1. 2 months
2. 4 months
3. 6 months
4. 12 months
3. 6 months
The nurse is evaluating the developmental level of a 2-year-old. Which does the nurse expect to observe in this child?
A. Uses a fork to eat
B. Uses a cup to drink
C. Pours own milk into cup
D. Uses a knife for cutting food
B. Uses a cup to drink.
An adolescent boy tells the nurse that he has recently had homosexual feelings. The nurse's response should be based on knowledge that:
1. This indicates that the adolescent is
homosexual.
2. This indicates that the adolescent will
become homosexual as an adult.
3. The adolescent should be referred for
psychotherapy.
4. The adolescent should be encouraged to
share his feelings and experiences.
4. The adolescent should be encouraged to
share his feelings and experiences.
A 1,000-gram neonate is being admitted to the neonatal intensive care unit. The surfactant Survanta (beractant) has just been prescribed to prevent respiratory distress syndrome. Which of the following actions should the nurse take while administering this medication?
1. Flush the intravenous line with normal saline solution.
2. Assist the neonatologist during the intubation procedure.
3. Inject the medication deep into the vastus lateralis muscle.
4. Administer the reconstituted liquid via an oral syringe.
2. Assist the neonatologist during the intubation procedure.
A parent asks the nurse what will need to be done to relieve the constipation of her child who also has cystic fibrosis (CF). Which is the nurse’s best response?
1. “Your child likely has an obstruction and will require surgery.”
2. “Your child will likely be given IV fluids.”
3. “Your child will likely be given MiraLAX.”
4. “Your child will be placed on a clear liquid diet.”
3. “Your child will likely be given MiraLAX.”
A maternity nurse is providing instruction to a new mother regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial development theory, the nurse would instruct the mother to:
1. Allow the newborn infant to signal a need
2. Anticipate all of the needs of the newborn infant
3. Avoid the newborn infant during the first 10 minutes of crying
4. Attend to the newborn infant immediately when crying
1. Allow the newborn infant to signal a need