infant
6. The nurse is providing anticipatory guidance to parents of a 12-month-old. Which statement by the parent requires correction?
A. "I will keep my baby in a rear-facing car seat."
B. "I will avoid giving my baby small, hard foods like grapes and hot dogs."
C. "I will give my baby a security blanket to help with anxiety."
D. "I will put my baby to sleep on their stomach so they don’t choke on spit-up."
D. "I will put my baby to sleep on their stomach so they don’t choke on spit-up."
6. A 2-year-old hospitalized for pneumonia resists procedures and repeatedly shouts “No!” when nurses approach. The parent asks if this behavior is concerning. The nurse’s BEST response is:
A. “This is a sign of oppositional defiant disorder and should be addressed early.”
B. “This negativism is normal in toddlers and reflects developing autonomy.”
C. “This indicates the illness has affected your child’s social development.”
D. “This means your child is regressing; we will need to start therapy.”
B. “This negativism is normal in toddlers and reflects developing autonomy.”
2. A parent tells the nurse, “My 5-year-old lies all the time. Should I punish her every time?” Which is the best response by the nurse?
A. “Preschool children often lie because of magical thinking and imagination. Gently correct her without shaming.”
B. “Lying in this age group is abnormal and should be consistently punished.”
C. “You should ignore the lying until she grows out of it.”
D. “It’s a sign of guilt and may indicate deeper emotional problems.”
A. “Preschool children often lie because of magical thinking and imagination. Gently correct her without shaming.”
10. During a health promotion session, the nurse emphasizes safety with adolescents. Which points should be prioritized? Select all that apply.
A. Importance of wearing seatbelts and avoiding distracted driving.
B. Risks of firearm access and safe storage.
C. Encouraging total independence from parental rules to build identity.
D. Discussing dangers of tanning and unprotected sun exposure.
E. Strategies to prevent substance-related accidents.
A,B,D,E
5. A 10-year-old is admitted with full-thickness burns covering 20% of total body surface area. Which finding indicates the nurse’s interventions are effective in preventing hypovolemic shock?
A. Heart rate increases from 110 to 132 bpm.
B. Urine output is 1 mL/kg/hr.
C. Blood pressure drops from 100/62 to 88/60 mmHg.
D. Capillary refill time is greater than 3 seconds.
B. Urine output is 1 mL/kg/hr.
4. A 2-month-old infant is in the clinic for a well-child check. Which finding should the nurse consider abnormal?
A. The infant briefly opens hands.
B. The infant holds head up when prone.
C. The infant consistently ignores loud noises.
D. The infant moves all four extremities.
C. The infant consistently ignores loud noises.
3. The parent of a 2-year-old reports that the child says only two- or three-word sentences like “want juice” and “go park.” The nurse’s BEST response is:
A. “This is delayed speech; your child should be speaking in complete sentences by now.”
B. “This is normal telegraphic speech for toddlers and shows appropriate language development.”
C. “This may indicate autism; you should seek a referral to speech therapy immediately.”
D. “This is abnormal; toddlers at this age usually use complex grammar.”
B. “This is normal telegraphic speech for toddlers and shows appropriate language development.”
8. Which finding in a 5-year-old requires follow-up?
A. Vocabulary of 2,100 words
B. Plays cooperatively with peers
C. Unable to concentrate on one activity for more than 3 minutes
D. Prints some letters
C. Unable to concentrate on one activity for more than 3 minutes
6. A school nurse is assessing vision in a 7-year-old. Which findings suggest possible amblyopia (lazy eye)? (Select all that apply.)
A. Squinting while reading the board
B. Poor hand–eye coordination in sports
C. Rubs eyes frequently during homework
D. One eye focuses better than the other
E. Sleeps less than 10 hours a night
A,B,C,D
4. SATA. A nurse is caring for a 4-year-old with atopic dermatitis. Which nursing interventions are appropriate?
A. Apply an emollient such as Eucerin immediately after bathing.
B. Keep the child’s nails trimmed short.
C. Use a perfumed bubble bath to soothe itching.
D. Encourage cotton clothing instead of wool.
E. Apply topical corticosteroid before moisturizing.
A,B,D
3. A nurse provides anticipatory guidance to the parents of a 4-month-old. Which teaching is MOST important to prioritize?
A. Introduce solid foods like rice cereal.
B. Expect the infant to babble and imitate sounds.
C. Keep the infant in a rear-facing car seat in the back seat.
D. Allow the infant to sleep with a small stuffed animal for comfort.
C. Keep the infant in a rear-facing car seat in the back seat.
2. A nurse is preparing to give an intramuscular injection to a 2-year-old. Which therapeutic communication techniques are MOST appropriate? (Select all that apply.)
A. Allow the toddler to choose which arm to use
B. Offer a favorite stuffed animal for comfort during the procedure
C. Explain that the injection will prevent the child from getting sick forever
D. Restrain the child firmly without explanation to get it over quickly
E. Use simple, concrete language such as “a quick poke”
A, B, E
3. A nurse is preparing anticipatory guidance for a group of parents with preschoolers. Which statements are appropriate to include? (Select all that apply.)
A. “Preschoolers may develop imaginary friends, which is a normal way to practice social skills.”
B. “Discipline should focus on consistency and setting clear limits, not shame or guilt.”
C. “Night terrors typically occur in REM sleep and the child can recall them in detail.”
D. “Offer small, healthy snacks and allow the child to decide when to stop eating.”
E. “Preschoolers usually understand cause-and-effect reasoning in most situations.”
A. “Preschoolers may develop imaginary friends, which is a normal way to practice social skills.”
B. “Discipline should focus on consistency and setting clear limits, not shame or guilt.”
D. “Offer small, healthy snacks and allow the child to decide when to stop eating.”
8. A 15-year-old is hospitalized after an intentional overdose. Which nursing intervention is the highest priority?
A. Encourage journaling to express emotions.
B. Establish a one-to-one observation for safety.
C. Facilitate a family therapy meeting.
D. Assess academic stressors and peer influences.
B. Establish a one-to-one observation for safety.
8. A 12-year-old presents with a red rash on the leg after hiking in the woods. The rash is flat, round, and expanding with central clearing. The nurse suspects Lyme disease. Which intervention should be implemented first?
A. Administer prescribed oral antibiotics.
B. Draw blood for Lyme serology.
C. Apply a topical corticosteroid to the rash.
D. Educate the family about long-term complications.
A. Administer prescribed oral antibiotics.
6. The nurse is assessing language development in infants. Which findings are appropriate for the age given? (Select all that apply.)
A. A 2-month-old cries when uncomfortable and calms with a parent’s voice
B. A 4-month-old smiles at their reflection
C. A 6-month-old turns to their name and babbles
D. A 9-month-old uses “dada” nonspecifically and gestures
E. A 12-month-old says “mama” with meaning and imitates gestures
A, C, D, E
8. The nurse is caring for four toddlers. Which child requires the most immediate follow-up?
A. A 15-month-old with a soft anterior fontanel
B. A 2-year-old with a vocabulary of 50 words and frequent echolalia
C. A 30-month-old who cannot jump with both feet
D. A 3-year-old who has not yet achieved daytime bowel control
C. A 30-month-old who cannot jump with both feet
4. A nurse is planning teaching for parents of a 3-year-old about discipline. Which strategies are most appropriate? (Select all that apply.)
A. Use consistent rules and limits.
B. Provide long time-outs to ensure the child learns.
C. Acknowledge and praise positive behaviors.
D. Offer realistic choices when setting limits.
E. Use reasoning and abstract explanations about consequences.
A,C,D
10. A nurse observes the following children on a school playground. Which child should be assessed first?
A. A 9-year-old who avoids eye contact and refuses to play with peers
B. A 10-year-old who stumbles frequently and has difficulty catching a ball
C. A 7-year-old who has imaginary friends during play
D. An 11-year-old who is anxious about an upcoming spelling test
B
9. SATA. A nurse is assessing a child with suspected impetigo. Which findings would support the diagnosis?
A. Honey-colored crusts around the mouth
B. Vesicles and pustules with erythematous base
C. Severe nighttime pruritus with visible burrows
D. History of exposure to strep or staph infection
E. Lesions that spread easily when scratched
A,B,D,E
2. A 9-month-old is brought to the clinic. Which findings should concern the nurse? (Select all that apply.)
A. Infant is unable to sit unsupported
B. Infant uses a raking motion to pick up objects
C. Infant cries when mother leaves the room
D. Infant does not babble or make consonant sounds
E. Infant pulls to stand using furniture
A. Infant is unable to sit unsupported
D. Infant does not babble or make consonant sounds
5. The nurse is assessing developmental milestones. Which findings in a 18-month-old require follow-up? (Select all that apply.)
A. Walking independently
B. Does not try to use a spoon
C. Cannot stack more than 2 blocks
D. Does not scribble spontaneously
E. Is unable to say seat self in chair
B,C,D,E
6. The nurse is reviewing developmental milestones with parents of a 3-year-old. Which of the following should the child be able to do? (Select all that apply.)
A. Ride a tricycle
B. Copy a triangle
C. String macaroni into a necklace
D. Use a fork
E. Draw a person with at least 6 body parts
A. Ride a tricycle
C. String macaroni into a necklace
D. Use a fork
4. The nurse is evaluating psychosocial development in a 7-year-old. Which behaviors indicate progression in Erikson’s industry vs inferiority stage? (Select all that apply.)
A. Becomes upset when not chosen for a group project
B. Shows pride after completing a model airplane
C. States, “I can’t do anything right. I’m stupid.”
D. Joins a soccer team and practices regularly
E. Refuses to participate in any activities due to fear of failure
A,B,D
3. A 2-year-old presents to the ED with scald burns to the anterior trunk and both arms. The child weighs 15 kg. Using the Parkland formula, how many milliliters of fluid should the nurse anticipate administering over the first 8 hours?
A. 540 mL
B. 720 mL
C. 1080 mL
D. 1440 mL
C
Parkland formula: 4 mL × 15 kg × 36 = 2160 mL/24 hr
First 8 hrs = ½ total = 1080 mL