A nurse is collecting data from a 9-month-old infant. Which of the following findings would require further
intervention?
a. Positive Babinski reflex
R ... [Show More] The Babinski reflex disappears after 1 year of age. Therefore, a 9-month-old infant with a positive
Babinski reflex is a finding that does not require further intervention
b. Positive Moro reflex
R The Moro reflex disappears approximately at 3-4 months of age. Therefore, a 9-month-old infant
with a positive Moro reflex is a findings that requires further intervention
c. Negative Doll’s eye reflex
R A negative Doll’s eye reflex is a normal finding. Therefore, a 9-month-old infant w/ a negative Doll’s
eye reflex is a finding that doesn’t require further intervention
d. Negative Crawl reflex
R A negative Crawl reflex disappears after 6 months of age. Therefore, a 9-month-old infant with a
negative Crawl reflex is a finding that does not require further intervention
2. During a routine well child check-up, a nurse is reinforcing teaching to a parent who reports having difficulty getting a
preschool-age child to go to bed. Which of the following statements indicates to the nurse that the parent
understands how to foster a consistent bedtime for the preschooler?
a. "I will allow my child to cry himself to sleep each night.”
R While crying for brief periods of time is not harmful to the child, it may promote a sense of fear
and insecurity and discourage the child from going to sleep.
b. "I will let my child fall asleep with me, and then move him to his own bed.”
R Allowing the child to routinely come into the parent’s bed fosters the idea that this will be the
norm. The child may then be unwilling to sleep alone.
c. "I will make sure the room is dark when placing my child in bed.”
R Darkened rooms may elicit fear in a preschooler.
d. "I will encourage my child to fall asleep with his favorite toy.”
R Transitional objects, such as a blanket or toy, will provide a sense of comfort and allow the child to
fall asleep more quickly.
3. A nurse is collecting data about a 6-year-old client. Which statement by the client's parent should concern the nurse?
a. "The teacher says my child has to squint to see the board."
R Squinting to see the board may indicate a vision problem. It is essential to check children for
hearing and vision problems. If not identified and corrected early, they lead to frustration and a
decreased ability to learn.
b. "My child has recently lost both front top teeth."
R Children of this age begin to lose their deciduous teeth to accommodate the emergence of their
permanent teeth. This is an expected finding.
c. "My child often cheats when we play board games."
R Children of this age often cheat to win at games because they feel winning is most important. This
is an expected finding.
d. "Sometimes my child acts bossy with his friends."
R Children of this age are often bossy and are learning how to interact with peers. This is an
expected finding.
4. A nurse is talking to a parent who is concerned about her hospitalized 5-year-old child's behavior and asks the nurse if
it is "normal." The nurse explains that regression is common in hospitalized children and may manifest by which of the
following?
a. Bedwetting several times a day
R Bedwetting by a preschooler who does not usually do so is a sign of regression in preschoolers.
b. Crying when the parent leaves
R This behavior is expected with preschoolers and is not a sign of regression.
c. Eating only food from home
R Preschoolers are reluctant to make changes in their dietary habits when ill. This is not a sign of
regression.
d. Cuddling a threadbare blanket at bedtime
R Transitional objects are helpful in any situation where a child feels anxiety or stress. This is not a
sign of regression.
5. A school nurse is talking with a 13-year-old female at her annual health screening visit. Which of the following client
comments should concern the nurse?
a. "My parents treat me like a baby sometimes."
R This is an expected comment. Adolescence can be a time of great struggle between independence
and dependence for both the child and the parents.
b. "I haven't gotten my period yet, and all my friends have theirs."
R Adolescents constantly compare themselves to their peers and feel very isolated if there are any
differences. Onset of menses varies and this client is still within the appropriate time frame.
c. "None of the kids at this school like me, and I don't like them either."
R This statement should concern the nurse, as the peer group is critical to adolescent development
and sense of self-esteem. This comment needs to be explored in greater depth.
d. "There's a pimple on my face, and I worry that everyone will notice it."
R Adolescents constantly compare themselves to their peers and feel very isolated if there are any
differences.
6. The nurse is caring for a hospitalized adolescent. The nurse understands that which major developmental task is
important during adolescence?
a. Building a sense of trust
R Building a sense of trust is not an appropriate developmental task of adolescence.
b. Learning to utilize creative energies
R Learning to utilize creative energies is not a developmental task of adolescence.
c. Learning to defer gratification
R Learning to defer gratification is not an appropriate developmental task of adolescence.
d. Defining a sense of self
R Establishing an identity or defining a sense of self is the major adolescent developmental task.
7. A nurse is talking to the parents of an 8-month-old who will be hospitalized for surgery. Which of the following actions
should the nurse explain to the parents will help prepare the infant for the hospital?
a. Buy a new toy and give it to the infant at the hospital.
R This action could be an effective anxiety-reduction strategy with a preschooler or school-age child,
as a new toy could provide the child with distraction. This is not an appropriate action to take for a
hospitalized infant.
b. Bring the infant’s favorite blanket to the hospital.
R Infants of this age have separation anxiety and often need a transitional object, such as a blanket
or toy, that brings them comfort. The transitional object is especially important when the child is
in unfamiliar surroundings, or the parent is not there to provide comfort. Having the object will
help to provide the infant with a sense of security.
c. Purchase new loose-fitting, soft pajamas for the child.
R This action could be an effective anxiety-reduction strategy with an older school-age child or
adolescent, as new clothes could help with the child’s anxiety about body image. This is not an
appropriate action to take for a hospitalized infant.
d. Read the child a story about hospitalization.
R This action could be an effective anxiety-reduction strategy with a preschooler or school-age child
because it will help to prepare the child for a new, anxiety- producing experience. This is not an
appropriate action to take for a hospitalized infant.
8. A nurse is planning care for a hospitalized 4-year-old child. The nurse should include providing a
a. plastic stethoscope.
R Preschool play centers on imitation of adults. Providing a stethoscope allows the child to imitate
the staff and helps ease the fear of unfamiliar equipment.
b. brightly colored mobile.
R A brightly colored mobile is appropriate for a very young infant. It would not meet the activity
needs of a preschooler.
c. jigsaw puzzle.
R A jigsaw puzzle is too difficult for most preschoolers and will frustrate rather than entertain the
child.
d. helium-filled latex balloon.
R Helium balloons might entertain the child, but the rubber in a deflated latex balloon presents a
choking hazard.
9. At the preoperative visit before an elective surgery, the nurse is planning to prepare a 9-year-old client for IV catheter
insertion. When reinforcing teaching, the nurse will first
a. explain to the client's parents what they can expect during and after IV insertion.
R While this is both important and appropriate, this is not the first action the nurse should take.
b. provide an opportunity for the client to see and touch IV tubing and supplies.
R While this is important and appropriate, it is best initiated at the conclusion of the visit.
c. describe the insertion procedure to the client, emphasizing sensory aspects.
R While this is important and appropriate, it is not the first action the nurse should take.
d. ask the client what he knows about having an IV infusion. [Show Less]
