2. The nurse is examining a Ans: C
10-month-old boy who was born 10 Feedback:The child's head size is
weeks early. Which large for his adjusted age (7.5
finding is cause for concern? months), which would be cause for
A) The child has doubled his birth concern. Birth weight doubles by
weight. about 4 months of age. Plantar grasp
B) The child exhibits plantar grasp reflex does not disappear until 9
reflex. months adjusted age. Primary teeth
C) The child's head circumference is may not erupt until 8 months adjusted
19.5 inches. age.
D) No primary teeth have erupted
yet.
3. The nurse is teaching a new mother Ans: A
about the drastic growth and devel- Feedback:
opmental changes By 6 months of age the infant's brain
her infant will experience in the first weighs half that of the adult brain;
year of life. Which statement de- at age 12 months, the brain weighs
scribes a developmental milestone 2.5 times what it did at birth. Most in-
occurring in infancy? fants double their birthweight by 4 to
A) By 6 months of age the infant's 6 months of age and triple their birth-
brain weighs half that of the adult weight by the time they are 1 year
brain; at age 12 old. The head circumference increas-
months, the brain weighs 2.5 times es rapidly during the first 6 months:
what it did at birth. the average increase is about 0.6
B) Most infants triple their birth- inch (1.5 cm) per month. The heart
weight by 4 to 6 months of age and doubles in size over the first year
quadruple their of life. As the cardiovascular system
birthweight by the time they are 1 matures, the average pulse rate de-
year old. creases from 120 to 140 in the new-
C) The head circumference increas- born to about 100 in the 1-year-old.
es rapidly Mduring the first 6
months: the average
increase is about 1 inch per month.
D) The heart triples in size over the
first year of life; the average pulse
, PEDS TEST BANK FINAL
rate decreases
from 120 to 140 in the newborn to
about 100 in the 1-year-old.
4. A new mother shows the nurse that Ans: B
her baby grasps her finger when eedback:Primitive reflexes are sub-
she touches the cortical and involve a whole-body re-
baby's palm. How might the nurse sponse. Selected primitive reflexes
respond to this information? present at birth include Moro, root,
A) 'This is a primitive reflex known suck, asymmetric tonic neck, plantar
as the plantar grasp.' and palmar grasp, step, and Babin-
B) 'This is a primitive reflex known ski. During the palmar grasp, the in-
as the palmar grasp.' fant reflexively grasps when the palm
C) 'This is a protective reflex known is touched. The plantar grasp occurs
as rooting.' when the infant reflexively grasps
D) 'This is a protective reflex known with the bottom of the foot when pres-
as the Moro reflex.' sure is applied to the plantar surface.
The root reflex occurs when the in-
fant's cheek is stroked and the in-
fant turns to that side, searching with
mouth. The Moro reflex is displayed
when with sudden extension of the
head, the arms abduct and move up-
ward and the hands form a "C."
5. Which reflex, if found in a B
4-month-old infant, would cause the
nurse to be concerned? Feedback:Appropriate appearance
A) Plantar grasp B) Step and disappearance of primitive re-
C) BabinskiD) Neck righting flexes, along with the development
of protective reflexes, indicates a
healthy neurologic system. The step
reflex is a primitive reflex that ap-
pears at birth and disappears at 4 to
8 weeks of age. The plantar grasp re-
flex is a primitive reflex that appears
at birth and disappears at about the
age of 9 months. The Babinski reflex
is a primitive reflex that appears at
, PEDS TEST BANK FINAL
birth and disappears around the age
of 12 months. The neck righting re-
flex is a protective reflex that appears
around the age of 4 to 6 months and
persists.
6. The nurse caring for newborns Ans: A, D, E, F
knows that infants exhibit phenom-
enal increases in their Feedback: At 1 month the infant lifts
gross motor skills over the first 12 and turns the head to the side in the
months of life. Which statements prone position. At 7 months the infant
accurately describe the typical in- sits alone with some use of hands for
fant's achievement of these mile- support. At 9 months the infant crawls
stones? Select all answers that ap- with the abdomen off the floor. At 12
ply. months the infant walks independent-
A) At 1 month the infant lifts and ly. At 4 months the infant lifts the head
turns the head to the side in the and looks around. At 10 months the
prone position. infant pulls to stand up.
B) At 2 months the infant rolls from
supine to prone to back again.
C) At 6 months the infant pulls to
stand up
D) At 7 months the infant sits alone
with some use of hands for support.
E) At 9 months the infant crawls with
the abdomen off the floor.
F) At 12 months the infant walks in-
dependently.
7. The nurse is teaching a new mother Ans: B
about the development of sensory
skills in her Feedback:Though hearing should be
newborn. What would alert the fully developed at birth, the other
mother to a sensory deficit in her senses continue to develop as the
child? infant matures. The newborn should
respond to noises. Sight, smell, taste,
A) The newborn's eyes wander and and touch all continue to develop af-
occasionally are crossed. ter birth. The newborn's eyes wan-
B) The newborn does not respond to der and occasionally cross, and the
, PEDS TEST BANK FINAL
a loud noise. newborn is nearsighted, preferring to
C) The newborn's eyes focus on view objects at a distance of 8 to
near objects. 15 inches. Holding, stroking, rocking,
D) The newborn becomes more alert and cuddling calm infants when they
with stroking when drowsy. are upset and make them more alert
when they are drowsy.
8. The nurse is assessing a Ans: B
4-month-old boy during a sched- Feedback:The fact that the child does
uled visit. Which findings might sug- not vocally respond to voices might
gest a developmental problem? suggest a developmental problem. At
A) The child does not babble. 4 to 5 months of age most children
B) The child does not vocally re- are making simple vowel sounds,
spond to voices. laughing aloud, doing raspberries,
C) The child never squeals or yells. and vocalizing in response to voic-
D) The child does not say dada and es. The child is too young to babble,
mama squeal, yell, or say dada or mama.
9. The nurse observes an infant inter- Ans: B, C, D, F
acting with his parents. What are Feedback:The infant exhibits a first
normal social real smile at age 2 months. By about
behavioral developments for this 3 months of age the infant will start an
age group? Select all that apply. interaction with a caregiver by smil-
A) Around 5 months the infant may ing widely and possibly gurgling. The
develop stranger anxiety. 3- to 4-month-old will also mimic the
B) Around 2 months the infant ex- parent's facial movements, such as
hibits a first real smile. widening the eyes and sticking out
C) Around 3 months the infant the tongue. Separation anxiety may
smiles widely and gurgles when in- also start in the last few months of in-
teracting with the fancy. Around the age of 8 months the
caregiver. infant may develop stranger anxiety.
D) Around 3 months the infant At 6 to 8 months of age the infant may
will mimic the parent's facial move- enjoy socially interactive games such
ments, such as as patty-cake and peek-a-boo.
sticking out the tongue.
E) Around 3 to 6 months of age the
infant may enjoy socially interactive
games such
as patty-cake and peek-a-boo.
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