The nurse is assessing a 3-year-old toddler. what is the expected weight gain for this age child?

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1. The nurse is testing reflexes in a four-month-old infant as part of the neurologic assessment. Which of the following findings would indicate an abnormal reflex pattern and an area of concern in a four-month-old infant?

A. Closes hand tightly when palm is touched.

B. Begins strong sucking movements when mouth area is stimulated.

C. Hyperextends toes in response to stroking sole of foot upward.

D. Does not extend and abduct extremities in response to loud noise.

2. The mother of a three-month-old infant asks the nurse when she can start feeding her baby solid food. Which of the following should the nurse include in teaching this mother about the nutritional needs of infants?

A. Infant cereal can be introduced by spoon when the extrusion reflex fades.

B. Solid foods should be given as soon as the infant's first tooth erupts.

C. Pureed food can be offered when the infant has tripled his birth weight.

D. Infant formula or breast milk provides adequate nutrients for the first year.

3. The nurse is assessing a six-month-old infant during a well child visit. The nurse makes all of the following observations. Which of the following assessments made by the nurse is an area of concern indicating a need for further evaluation?

A. Moderate head lag when pulled to sitting position.

B. Absence of Moro reflex.

C. Closed posterior fontanel.

D. Three pound weight gain in two months.

4. The nurse is giving anticipatory guidance regarding safety and injury prevention to the parents of an 18-month-old toddler. Which of the following actions by the parents indicates understanding of the safety needs of a toddler?

A. Teach the child swimming and water safety.

B. Use automobile booster seat with lap belt.

C. Allow child to cross the street with four-year-old sibling.

D. Correct Supervise the child in outdoor, fenced play areas.

5. The community health nurse is making a newborn follow-up home visit. During the visit the two-year-old sibling has a temper tantrum. The parent asks the nurse for guidance in dealing with the toddler's temper tantrums. Which of the following is the most appropriate nursing action?

A. Help the child understand the rules.

B. Leave the child alone in his bedroom.

C. Explain that the toddler is jealous of the new baby.

D. Suggest that the parent ignore the child's behavior.

6. The parent of a three-year-old child brings the child to the clinic for a well child checkup. The history and assessment reveals the following findings. Which of these assessment findings made by the nurse is an area of concern and requires further investigation?

A. Uses gestures to indicate wants.

B. Unable to ride a tricycle.

C. Has ability to hop on one foot.

D. Weight gain of four pounds in last year.

7. The parents of a four-year-old child tell the nurse that the child has an invisible friend named "Felix." The child blames "Felix" for any misbehavior and is often heard scolding "Felix," calling him a "bad boy." The nurse understands that the best interpretation of this behavior is which of the following?

A. A way for the child to assume control.

B. A delay in moral development.

C. Impaired parent-child relationship.

D. Inconsistent parental discipline strategies.

8. The nurse is caring for a five-year-old child who is in the terminal stages of acute leukemia. The child refuses to go to sleep and is afraid that his parents will leave. The nurse recognizes that the child suspects he is dying and is afraid. Which of the following questions about death is most likely to be made by a five-year-old child?

A. "Why do children die if they're not old?"

B. "What will my friends do when I die?"

C. "What does it feel like when you die?"

D. "Who will take care of me when I die?"

9. The parents of an eight-year-old child bring the child into the clinic for a school physical. The nurse makes all of the following assessments. Which assessment finding is an area of concern and needs further investigation?

A. Has lost three deciduous teeth and has the central and lateral incisors.

B. Has many evening rituals and resists going to bed at night.

C. Complains of a stomach ache on test days at school.

D. Refers to self as being too dumb and too small during the exam.

10. The nurse is performing a neurologic assessment on an eight-year-old child. As part of this neurologic assessment the nurse is assessing how the child thinks. Which of the following abilities best illustrates that the child is developing concrete operational thought?

A.Tells time in terms of after breakfast and before lunch.

B. Describes a ball as both red and round.

C. Able to make change from a dollar bill.

D. Able to substitute letters for numbers in simple problems.

Answers and Rationale:

1. Correct A

Rationale: The palmar grasp is present at birth. The palmar grasp lessens by age three months and is no longer reflexive. The infant is able to close hand voluntarily.

2. Correct A

Rationale: Infant cereal is generally introduced first because of its high iron content. The infant is able to accept spoon feeding at around four to five months when the tongue thrust or extrusion reflex fades.

3. Correct A

Rationale: By four to six months, head control is well established. There should be no head lag when infant is pulled to a sitting position by the age of six months.

4. Correct D

Rationale: The child has great curiosity and has the mobility to explore. Toddlers need to be supervised in play areas. Play areas with soft ground cover and safe equipment need to be selected.

5. Correct D

Rationale: The best approach toward extinguishing attention-seeking behavior is to ignore it as long as the behavior is not inflicting injury.

6. Correct A

Rationale: This behavior indicates a delay in language and speech development. The child may not be able to hear. The child should have a vocabulary of about 900 words and use complete sentences of three to four words.

7. Correct A

Rationale: Imaginary friends are a normal part of development for many preschool children. These imaginary friends often have many faults. The child plays the role of the parent with the imaginary friend. This becomes a way of assuming control and authority in a safe situation.

8. Correct D

Rationale: The greatest fear of preschool children is being left alone and abandoned. Preschool children still think as though they are alive and need to be taken care of.

9. Correct D

Rationale: The school-age years are very important in the development of a healthy self-esteem. These statements by the eight-year-old child indicate a risk for development of a sense of inferiority and need further assessment.

10. Correct C

Rationale: This ability illustrates the concept of conservation, which is one of the major cognitive tasks of school-age children.

11. The nurse is caring for a 10-year-old child during the acute phase of rheumatic fever. Bedrest is part of the child's plan of care. Which of the following diversional activities is developmentally appropriate and meets the health needs of this child in the acute phase of rheumatic fever?

A. Playing basketball with a hoop suspended from the bed.

B. Using hand-held computer video games.

C. Sorting and organizing baseball cards in a notebook.

D. Using art supplies to make drawings about the hospital experience.

12. The nurse is caring for a 13-year-old who has been casted following spinal instrumentation surgery to correct idiopathic scoliosis. The nurse is helping the teen and family plan diversional activities while the teen is in the cast. Which of the following activities would be most appropriate to support adolescent development while the teen is casted?

A. Take the teen shopping at the mall in a wheelchair.

B. Have teen regularly attend special school activities for own class.

C. Encourage siblings to spend time with teen watching television and movies.

D. Plan family evenings playing a variety of board games.

13. A two-month-old infant is in the clinic for a well baby visit. Which of the following immunizations can the nurse expect to administer?

14. An 18-month-old child with a history of falling out of his crib has been brought to the emergency room by the parents. Examination of the child reveals a skull fracture and multiple bruises on the child's body. Which of the following findings obtained by the nurse is most suggestive of child abuse?

A. Poor personal hygiene of the child.

B. Conflicting explanations about the accident from the parents.

C. Cuts and bruises on the child's lower legs in various stages of healing.

D. Inability of the parents to comfort the child.

15. The nurse is discussing the risk of sudden infant death syndrome (SIDS) in infants with the parents whose second baby died of SIDS six months ago. The parents express fear that other children will die from SIDS since they have already had one baby die. Which of the following statements made by the parents indicate their understanding of the relationship of future children and the risk of SIDS?

A. "There is a 99% chance that we will not have another baby die of SIDS."

B. "There is medicine that can be used to stimulate the heart rate while the baby is sleeping."

C. "Genetic testing is available to determine the likelihood of another baby dying from SIDS."

D. "Any new baby will be on home monitoring for one year to prevent SIDS."

16. A ten-day-old baby is admitted with 5% dehydration. The nurse notes which of the following signs?

17. The nurse is asked why infants are more prone to fluid imbalances than adults. The response is

A. infants ingest a lesser amount of fluid per kilogram.

B. infants have functionally immature kidneys.

C. adults have a greater body surface area.

D. adults have a greater metabolic rate.

18. A 10-month-old weighs 10 kg and has voided 100 ml in the past four hours. The nurse determines normal urine output based on the fact that normal urine output is

19. A three-month-old is NPO for surgery. The nurse attempts to comfort him by

A. administering acetaminophen.

C. encouraging parents to leave so the child can rest.

D. giving 10 cc Pedialyte.

20. An 11-year-old is admitted for treatment of lead poisoning. The nurse includes which of the following in the plan of care?

A. Strict intake and output.

C. Heme-occult stool testing.

Answers and Rationale:

11. Correct C

Rationale: The middle childhood years are times for collections. The collections of middle to late school-age children become orderly, selective, and neatly organized in scrapbooks. This quiet activity supports the development of industry and concrete operational thought as well as the physical restrictions related to the rheumatic fever.

12. Correct B

Rationale: Early adolescents have a strong need to fit in and be accepted by their peers. Attending school activities helps the teen continue peer relationships and develop a sense of belonging.

13. Correct B

Rationale: Healthy infants at two months of age receive diphtheria, tetanus, and pertussis (DTP); hemophilus influenza (Hib); oral polio vaccine (OPV); and hepatitis B virus (HBV).

14. Correct B

Rationale: Incompatibility between the history and the injury is probably the most important criterion on which to base the decision to report suspected abuse.

15. Correct A

Rationale: Whether subsequent siblings of the SIDS infant are at risk is unclear. Even if the increased risk is correct, families have a 99% chance that their subsequent child will not die of SIDS.

16. Correct A

Rationale: Tachycardia is associated with dehydration.

7. Correct B

Rationale: Infant kidneys are unable to concentrate or dilute urine, to conserve or secrete sodium, or to acidify urine.

8. Correct B

Rationale: Normal urine output is 1–2 ml/kg/hour.

9. Correct B

Rationale: Non-nutritive sucking will help console and pacify him.

10. Correct A

Rationale: CaNaEDTA (treatment for lead poisoning) is nephrotoxic and strict intake and output records need to be kept.