1. While examining a 2-year-old child, the nurse in charge sees
that the anterior fontanel is open. The nurse should: A. No Notif tify y the the docto doctorr B. Look for other signs of abuse C. Recognize this as a normal nding D. Ask about a family history of ay!"achs disease
Answer: A. Notify the doctor Because the anterior fontanel normally closes bet#een ages 1$ and 1% months& the nurse should notify the doctor 'rom'tly of this nding. An o'en fontanel does not indicate abuse and is not associated #ith ay! "achs disease.
i nfant, the nurse in $. When administering an I.. in!ection to an infant, charge should use which site" A. Del elto toiid B. Dorsogluteal C. (entrogluteal D. (astus lateralis
Answer: #. $astus lateralis he recommend recommended ed in)ection site for an infant infant is the *astus *astus lateralis lateralis or rectus femoris muscles. he deltoid is ina''ro'riate. he dorsogluteal and *entrogluteal sites can be used only in toddlers #ho ha*e been #alking for about 1 year.
+. #uring a well-%a%y &isit, 'i(a as)s the nurse when she should
start gi&ing her infant solid foods. The nurse should instruct her to introduce which solid food *rst" A. A''le sauce B. ,gg #hites C. Rice cereal D. -ogurt
Answer: +. ice cereal Rice cereal is the rst solid food an infant should recei*e because it is easy to digest and is associated #ith fe# allergies. Net& the infant can recei*e 'ureed fruits& such as bananas& a''lesauce& and 'ears& follo#ed by 'ureed *egetables& egg yolks& cheese& yogurt& and nally& meat. ,gg #hites should not be gi*en until age / months because they may trigger a food allergy. 0. When performing a physical examination on an infant, the
nurse in charge notes a%normally low-set ears. This *ndings is associated with: A. togenous tetanus B. racheoeso'hageal stula C. Congenital heart defects D. Renal anomalies
Answer: #. enal anomalies Normally the to' of the ear aligns #ith an imaginary line dra#n across the inner and outer canthus of the eye. ,ars set belo# this line are associated #ith renal anomalies or mental retardation. Lo#!set ears do not accom'any otogenous tetanus& tracheoeso'hageal stula& or congenital heart defects.
2. Nurse Walter should expect a -year-old child to %e a%le to
perform which action" A. Ride a tricycle B. ie the shoelaces C. Roller!skates D. 3um' ro'e
Answer: A. ide a tricycle At age +& gross motor de*elo'ment and renement in eye!hand coordination enable a child to ride a tricycle. he ne motor skills re4uired to tie shoelaces and the gross motor skills re4uires for roller! skating and )um'ing ro'e de*elo' around age 2.
5. Nurse im is teaching a group of parents a%out otitis media.
When discussing why children are predisposed to this disorder, the nurse should mention the signi*cance of which anatomical feature" A. ,ustachian tubes B. Naso'haryn C. ym'anic membrane D. ,ternal ear canal
Answer: A. /ustachian tu%es 6n a child& ,ustachian tubes are short and lie in a horizontal 'lane& 'romoting entry of naso'haryngeal secretions into the tubes and thus setting the stage for otitis media. he naso'haryn& tym'anic
membrane& eternal ear canal ha*e no unusual features that #ould 'redis'ose a child to otitis media.
7. 0udden infant death syndrome 10I#0 is one of the most
common causes of death in infants. At what age is the diagnosis of 0I#0 most li)ely" A. At 1 to $ years of age B. At 6 #eek to 1 year of age& 'eaking at $ to 0 months C. At 5 months to 1 year of age& 'eaking at 18 months D. At 5 to % #eeks of age
Answer: 3. At I wee) to 4 year of age, pea)ing at 2 to 5 months "6D" can occur any time bet#een 1 #eek and 1 year of age. he incidence 'eaks at $ to 0 months of age.
%. Which of the following is the %est method for performing a
physical examination on a toddler A. 9rom head to toe B. Distally to 'roimally C. 9rom abdomen to toes& the to head D. 9rom least to most intrusi*e
Answer: #. 6rom least to most intrusi&e :hen eamining a toddler or any small child& the best #ay to 'erform the eam is from least to most intrusi*e. "tarting at the head or abdomen is intrusi*e and should be a*oided. ;roceeding from distal to 'roimal is ina''ro'riate at any age.
/. Which of the following organisms is responsi%le for the
de&elopment of rheumatic fe&er" A. "tre'tococcal 'neumonia B.
rou' A ?!hemolytic stre'tococcus D. "ta'hylococcus aureus
Answer: +. 7roup A 8-hemolytic streptococcus! Rheumatic fe*er results as a delayed reaction to inade4uately treated grou' A ?!hemolytic stre'tococcal infection.
18.
The nurse is assessing a new%orn who had undergone
&aginal deli&ery. Which of the following *ndings is least li)ely to %e o%ser&ed in a normal new%orn" A. une*en head sha'e B. res'irations are irregular& abdominal& +8!58 b'm c. @ moro re=e D. heart rate is %8 b'm
Answer #. heart rate is 9 %pm ! Normal heart rate of the ne#born is 1$8 to 158 b'm. Choices A& B& and C are normal assessment ndings @une*en head sha'e is molding.
11.
An in%orn error of meta%olism that causes premature
destruction of 3+" A. >5;D B.
C. ;henylketonuria D. Celiac Disease
Answer: A. 7;<#! >lucose!5!'hos'hate dehydrogenase deciency @>5;D is an !linked recessi*e hereditary disease characterised by abnormally lo# le*els of glucose!5!'hos'hate dehydrogenase @abbre*iated >5;D or >5;D<& a metabolic enzyme in*ol*ed in the 'entose 'hos'hate 'ath#ay& es'ecially im'ortant in red blood cell metabolism.
1$.
The nurse is assessing a =-month-old %oy for a well-%a%y
chec) up. Which of the following o%ser&ations would %e of most concern" A. he baby cannot say mamaE #hen he #ants his mother. B. he mother has not gi*en him nger foods. C. he child does not sit unsu''orted. D. he baby cries #hene*er the mother goes out.
Answer: +. The child does not sit unsupported.*er /8F 'ercent of babies can sit unsu''orted by nine months. Gost babies cannot say mamaE in the sense that it refers to their mother at this time.
1+.
+herry, the mother of an 44-month-old girl, /li(a%eth, is
in the clinic for her daughter>s immuni(ations. 0he expresses concern to the nurse that /li(a%eth cannot yet wal). The nurse correctly replies that, according to the #en&er #e&elopmental 0creen, the median age for wal)ing is: A. 1$ months. B. 12 months.
C. 18 months. D. 10 months.
Answer: A. 42 months.! By 1$ months& 28 'ercent of children can #alk #ell. And it is achie*ed by age 12mos
10.
A term neonate is to %e released from hospital at 2
days of age. Nurse (alerie eamines the neonateHs hands and 'alms. :hich of the follo#ing ndings re4uires further assessmentI a Many crease across the palm. b Absence of creases on the palm. c A single crease on the palm. d Two large creases across the palm.
12.
he mother asks #hen the soft s'otsE closeI he nurse
e'lains that the neonateHs anterior fontanel #ill normally close by ageJ a 2 to 3 months. b 6 to 8 months.
c 12 to 18 months. d 20 to 24 months. 15.
:hen 'erforming the 'hysical assessment& the nurse
e'lains to the mother that in a term neonate& sole creases areJ a Absent near the heels. b Evient !ner the heels only" c Spread over the entire foot. d Evient only towars the transverse arch.
17.
:hen assessing the neonateHs eyes& the nurse notes the
follo#ingK absence of tears& corneas of une4ual size& constriction of the 'u'ils in res'onse to bright light& and the 'resence of red circles on the 'u'ils on o'hthalmic eamination. :hich of these ndings needs further assessmentI a The absence of tears.
% Corneas of unequal size. c #onstriction of the p!pils. d The presence of re circles on the p!pils. 1%.
After teaching the mother about the neonateHs 'ositi*e
Babinski re=e& the nurse determines that the mother understands the instructions #hen she says that a 'ositi*e Babinski re=e indicatesJ. a $mmat!re m!scle coorination.
% Immature central nervous system. c %ossible lower spinal cor efect. d %ossible in&!ry to nerves that innervate the feet.
0ituation: Nurse ris is responsi%le for assessing a male neonate approximately 25 hours old. The neonate was deli&ered &aginally. '(.
The n!rse sho!l plan to assess the neonate)s physical
conition*.
a Miday !eteen feedings. b $mmeiately after a feeing. c After the neonate has been +%, for three ho!rs. d $mmeiately before a feeing.
20.
The n!rse notes a swelling on the neonate)s scalp that crosses
the s!t!re line. The n!rse oc!ments this conition as*
a #ephallic hematoma.
% Caput succedaneum. c -emorrhage eema. d %erinatal cap!t. 2'.
The n!rse meas!res the circ!mference of the neonate)s heas
an chest" an then eplains to the mother that when the two meas!rements are compare" the hea is normally abo!t*
a The same si/e as the chest.
% 2 centimeter larger than the chest. c 2 centimeter smaller than the chest. d 4 centimeter larger than chest. 22.
After eplaining the neonate)s cranial moling" the n!rse
etermines that the mother nees f!rther instr!ctions from which statement
a 1The moling is ca!se by an overriing of the cranial bones.
% "#he degree of molding is related to the amount of pressure on the head.$
c 1The moling will isappear in a few ays. d 1The fontanels maybe amage if the moling oes not resolve !icly. 23.
5hen instr!cting the mother abo!t the neonate)s nee for sensory
an vis!al stim!lation" the n!rse sho!l plan to eplain that the most highly evelop sense in the neonate is*
a Tas b mell
c #ouch d -earing
Nurse ?oan wor)s in a children>s clinic and helps with the care for well and ill children of &arious ages. 24.
A mother brings her 4 month ol infant to the clinic. The mother
ass the n!rse when she sho!l wean the infant from breastfeeing an begin !sing a c!p. +!rse 7oan sho!l eplain that the infant will show reainess to be weane by*
a Taing soli foos well. b leeping thro!gh the night.
c Shortening the nursing time. d Eating on a reg!lar sche!le. 2.
Mother Arlene says the infant)s physician recommens certain
foos b!t the infant ref!ses to eat them after breastfeeing. The n!rse sho!l s!ggest that the mother alter the feeing plan by*
a ,ffering esert followe by vegetable an meat. b ,ffering breast mil as long as the infant ref!ses to eat soli foo.
c Miing mince foo with cow)s mil an feeing it to the infant thro!gh a large hole nipple.
d %iving the infant a fe minutes of !reast and then offering solid food. 26.
5hich of the following abilities wo!l a n!rse epect a 4 month
ol infant to perform
a Sitting up ithout support. b 9esponing to pleas!re with smiles. c :rasping a rattle when it is offere. d T!rning from either sie to the bac. 2;.
5hen isc!ssing a seven month ol infant)s mother regaring the
motor sill evelopment" the n!rse sho!l eplain that by age seven months" an infant most liely will be able to*
a 5al with s!pport.
b Eat with a spoon. c tan while holing !nto a f!rnit!re
d Sit alone using the hands for support. 28.
A mother brings her one month ol infant to the clinic for chec<
!p. 5hich of the following evelopmental achievements wo!l the n!rse assess for
a miling an la!ghing o!t lo!. b 9olling from bac to sie. c -oling a rattle briefly.
d #urning the head from side to side. 2(.
A two month ol infant is bro!ght to the clinic for the first
imm!ni/ation against =%T. The n!rse sho!l aminister the vaccine via what ro!te
a ,ral.
% Intramascular c !bc!taneo!s d $ntraermal 30.
The n!rse teaches the client)s mother abo!t the normal reaction
that the infant might eperience '2 to 24 ho!rs after the =%T imm!ni/ation" which of the following reactions wo!l the n!rse isc!ss
a >ethargy.
% Mild fever. c =iarrhea d +asal #ongestion 3'.
An infant is observe to be competent in the following
evelopmental sills? stares at an ob&ect" place her hans to the mo!th an taes it off" coos an gargles when tal to an s!stains part of her own weight when hel to in a staning position. The n!rse correctly assesse infant)s age as*
a Two months.
% &our months c i months d Eight months. 32.
The mother says" 1the soft spot near the front of her baby)s hea
is still big" when will it close +!rse >ilibeth)s correct response wo!l be at*
a 2 to 4 months. b to 8 months. c ( to '2 months.
d 1' to 18 months. prop 33.
A mother states that she thins her (
slowly). 5hen eval!ating the infant)s evelopment" the n!rse wo!l not epect a normal (
a #reep an crawl. b egin to !se imitative verbal epressions.
c (ut an arm through a sleeve hile !eing dressed. d -ol a bottle with goo han B mo!th coorination. 34.
The mother of the (
foos to his iet" he spits everything o!t" she says. The n!rse sho!l teach the mother to*
a Mi new foos with form!la b Mi new foos with more familiar foos.
c )ffer ne foods one at a time. d ,ffer new foos after form!la has been offere. 3.
5hich of the following tass is typical for an '8
a #opying a circle b (ulling toys c %laying toy with other chilren d !iling a tower of eight blocs
36.
Mother 9i/a brings her normally evelope 3
for a chec
a 9iing a bicycle
% #ying shoelaces c tringing large beas d Csing bl!nt scissors 3;.
The mother tells the n!rse that she is having problem toilet<
training her 2
a 9ewars are too limite b Training e!ipment is inappropriate
c (arents ignore "accidents$ that occur during training d #he child is not develop mentally ready to !e trained 38.
A chil is not evelopmentally reay to be traine. A 2<'D2 year ol
chil is bro!ght to the clinic by his father who eplains that the chil is afrai of the ar an says 1no when ase to o something. The n!rse wo!l eplain that the negativism emonstrate by toler is fre!ently an epression of*
a *uest for autonomy b -yperactivity c eparation aniety d ibling rivalry 3(.
The n!rse wo!l eplain to the father which concept of %iaget)s
cognitive evelopment as the basis for the chil)s fear of arness
a 9eversibility
% Animism c #onservation of matter d ,b&ect permanence
40.
The mother says that she will be gla to let her chil br!sh her
teeth witho!t help" b!t at what age sho!l this begin +!rse 9oselyn sho!l respon at*
a 3 years b years
c + years d ; years 4'.
The n!rse eplaine to the mother that accoring to Ericson)s
framewor of psychosocial evelopment" play as a vehicle of evelopment can help the school age chil evelop a sense of*
a $nitiative
% Industry c $entity d $ntimacy 42.
The school n!rse is planning a series of safety an accient
prevention classes for a gro!p of thir graes. 5hat preventive meas!res sho!l the n!rse stress !ring the first class" nowing the leaing ca!se of inciental in&!ry an eath in this age
a lameife preserves c %rotective eyewear
d Auto seat !elts 43.
5hen assessing an '8
characteristics protr!ing abomen. 5hich of the following wo!l eplain the rationale for this finings
a $ncrease foo intae owing to age
% ,nderdeveloped a!dominal muscles c owlegge post!re d >inear growth c!rve
44.
$f parents eep a toler epenent in areas where he is capable
of !sing sills" the toler will evelop a sense of which of the following
a Mistr!st
% Shame c :!ilt d $nferiority 4.
5hich of the following fears wo!l the n!rse typically associate
with tolerhoo
a M!tilation b The ar c :hosts
d %oing to sleep 46.
A mother of a 2 year ol has &!st left the hospital to chec on her
other chilren. 5hich of the following wo!l best help the 2 year ol who is now crying inconsolably
a Taing a nap b %eer play gro!p c >arge c!ly og
d &avorite !lan-et 4;.
5hich of the following is an appropriate toy for an '8 month ol
a M!ltiple
c &inger paints d #omic oo 48.
5hen teaching parents abo!t typical toler eating patterns"
which of the following sho!l be incl!e
a &ood "ags$ b %reference to eat alone c #onsistent table manners d $ncrease in appetite
4(.
5hich of the following toys sho!l the n!rse recommen for a <
month ol
a A big re balloon b A tey bear with b!tton eyes c A p!sh
d A colorful !usy !o/
50.
5hich of the following when present in the !rine may ca!se a reish stain on the iaper of a newborn
A. Gucus B. ric acid crystals C. Bilirubin D. ,cess iron
3. ric acid crystals in the urine may 'roduce the reddish brick dustE stain on the dia'er. Gucus #ould not 'roduce a stain. Bilirubin and iron are from he'atic ada'tation. 21.
:hen assessing the ne#bornHs heart rate& #hich of the
follo#ing ranges #ould be considered normal if the ne#born #ere slee'ingI A. %8 beats 'er minute B. 188 beats 'er minute C. 1$8 beats 'er minute D. 108 beats 'er minute
3. he normal heart rate for a ne#born that is slee'ing is a''roimately 188 beats 'er minute. 6f the ne#born #as a#ake& the normal heart rate #ould range from 1$8 to 158 beats 'er minute.
2$.
:hich of the follo#ing is true regarding the fontanels of
the ne#bornI a. he anterior is triangular sha'edM the 'osterior is diamond sha'ed. b. he 'osterior closes at 1% monthsM the anterior closes at % to 1$ #eeks. c. he anterior is large in size #hen com'ared to the 'osterior fontanel. d. he anterior is bulgingM the 'osterior a''ears sunken. C. he anterior fontanel is larger in size than the 'osterior fontanel. Additionally& the anterior fontanel& #hich is diamond sha'ed& closes at 1% months& #hereas the 'osterior fontanel& #hich is triangular sha'ed& closes at % to 1$ #eeks. Neither fontanel should a''ear bulging& #hich may indicate increased intracranial 'ressure& or sunken& #hich may indicate dehydration. 2+.
:hich of the follo#ing grou's of ne#born re=ees belo#
are 'resent at birth and remain unchanged through adulthoodI A. Blink& cough& rooting& and gag B. Blink& cough& sneeze& gag C. Rooting& sneeze& s#allo#ing& and cough D. "te''ing& blink& cough& and sneeze
3. Blink& cough& sneeze& s#allo#ing and gag re=ees are all 'resent at birth and remain unchanged through adulthood. Re=ees such as rooting and ste''ing subside #ithin the rst year. 20.
:hich of the follo#ing describes the Babinski re=eI
A. he ne#bornHs toes #ill hy'eretend and fan a'art from dorsi=eion of the big toe #hen one side of foot is stroked u'#ard from the ball of the heel and across the ball of the foot. B. he ne#born abducts and =ees all etremities and may begin to cry #hen e'osed to sudden mo*ement or loud noise. C. he ne#born turns the head in the direction of stimulus& o'ens the mouth& and begins to suck #hen cheek& li'& or corner of mouth is touched. D. he ne#born #ill attem't to cra#l for#ard #ith both arms and legs #hen he is 'laced on his abdomen on a =at surface
A. :ith the babinski re=e& the ne#bornHs toes hy'eretend and fan a'art from dorsi=eion of the big toe #hen one side of foot is stroked u'#ard form the heel and across the ball of the foot. :ith the startle re=e& the ne#born abducts and =ees all etremities and may begin to cry #hen e'osed to sudden mo*ement of loud noise. :ith the rooting and sucking re=e& the ne#born turns his head in the direction of stimulus& o'ens the mouth& and begins to suck #hen the cheeks& li'& or corner of mouth is touched. :ith the cra#l re=e& the ne#born #ill attem't to cra#l for#ard #ith both arms and legs #hen he is 'laced on his abdomen on a =at surface.
