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Detailed Answer Key Growth and Development: Infants and Toddlers

1. A nurse is assessing a toddler at a well-child visit. At what point in the physical examination should the nurse examine the child's tympanic membrane? A. At the end Rationale: When examining a toddler, the nurse should follow a modified head-to-toe approach, starting at the head but deferring anything that the toddler is likely to view as invasive and traumatic to the very end. The toddler is likely to resist not only having the ears examined, but also anything that follows. B. At the beginning Rationale: The nurse should not examine the tympanic membranes first because the toddler is likely to view examination of the ear canal as invasive and traumatic. The toddler is likely to resist not only having the ears examined, but also anything that follows. C. Before examining the head and neck Rationale: The nurse should examine the head and neck before examining the tympanic membrane. D. Before auscultating the chest and abdomen Rationale: The nurse should auscultate the chest and abdomen before examining the tympanic membrane.

2. A nurse is caring for a 2-year-old child who is hospitalized and throws a tantrum when his parent leaves. Which of the following toys should the nurse provide to alleviate the child's stress? A. Set of building blocks Rationale: Although a set of building blocks is an age-appropriate toy for a 2-year-old child, it is not the most therapeutic toy. B. Toy hammer and pounding board Rationale: A toy hammer and pounding board helps the child to express the anger and frustration he feels about the parent leaving but lacks the verbal ability to express. C. Picture book about hospitals Rationale: Although a picture book is an age-appropriate toy for a 2-year-old child, it is not the most therapeutic toy. D. Stuffed animal Rationale: Although a stuffed animal is an age-appropriate toy for a 2-year-old child, it is not the most therapeutic toy.

3. A nurse is caring for an 18-month-old toddler who has been hospitalized for 10 days. After the toddler's mother leaves the room, the nurse observes the toddler sitting quietly in the corner of the crib, sucking her thumb. When

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Detailed Answer Key Growth and Development: Infants and Toddlers the nurse approaches the crib, the toddler turns away from the nurse. The nurse should understand that these behaviors indicate which of the following developmental reactions? A. An anxiety reaction Rationale: Hospitalization is stressful, regardless of the age of the client. However, for an 18-month-old toddler, separation from parents adds to that stress. The toddler's behavior indicates an anxiety reaction to the stress of hospitalization. Separation anxiety initially causes demonstrations of protest. Remaining sad and quiet when a parent leaves indicates the second response to separation anxiety, which is despair. B. Regression Rationale: The toddler's behavior is age-appropriate. C. Resentment toward the mother Rationale: This reaction is not age-appropriate. D. Developing autonomy Rationale: An 18-month-old toddler might be beginning to develop autonomy. However, remaining sad and quiet without protesting when a parent leaves is an unusual behavior for a toddler and is not related to developing autonomy.

4. A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings should the nurse expect? A. Closed posterior fontanel Rationale: The infant's posterior fontanel should close by about 8 weeks of age. B. Uses thumb and index fingers in a pincer grasp Rationale: A 9-month-old infant should be able to use his thumb and index fingers in a crude pincer grasp. C. Lateral incisors Rationale: An infant should develop upper lateral incisors between 9 and 13 months of age and lower lateral incisors at 10 to 16 months of age. D. Sitting steadily without support Rationale: At 6 months of age, most infants can sit only with support. An 8-month-old infant should be able to sit without support.

5. A nurse is teaching an assistive personnel to measure a newborn's respiratory rate. Which of the following statements indicates an understanding of why the respiratory rate should be counted for a complete minute? A. "Newborns are abdominal breathers." Rationale:

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Detailed Answer Key Growth and Development: Infants and Toddlers Newborns are abdominal breathers. However, this fact has no impact on obtaining a respiratory rate. B. "Newborns do not expand their lungs fully with each respiration." Rationale: The labor of breathing in a newborn varies. However, this fact has no impact on obtaining a respiratory rate. C. "Activity will increase the respiratory rate." Rationale: Activity will increase the respiratory rate. However, this fact has no impact on obtaining a respiratory rate. D. "The rate and rhythm of breath are irregular in newborns." Rationale: Newborns have an irregular respiratory rate and rhythm. Therefore, counting the respiratory rate for a complete minute is recommended to obtain an accurate rate.

6. A nurse is assessing the psychosocial development of a toddler. The nurse should recognize that this stage is characterized by which of the following? A. ?Imaginary playmates Rationale: At 4 to 5 years of age, children have imaginary playmates. B. Erikson's stage of initiative versus guilt Rationale: The stage of initiative versus guilt is typical of the preschool-age child. C. ?Demonstrations of sexual curiosity Rationale: Sexual curiosity is typical of the preschool-age child. D. ?Negative behaviors characterized by the need for autonomy Rationale: ?Assertion of autonomy is seen in toddlers as they begin their language and social development.

7. A nurse is assessing a 3-month-old infant. Which of the following findings should the nurse report to the provider? A. Inability to raise head when in prone position Rationale: A 3-month-old infant should be able to raise her head and shoulders from prone position; therefore, the nurse should report this finding to the provider. B. Inability to sit without support Rationale: An 8-month-old infant should be able to sit without support. C. Inability to pick up an object with her fingers Rationale:

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Detailed Answer Key Growth and Development: Infants and Toddlers A 6-month-old infant should be able to grasp objects with her fingers. D. Inability to bring an object to her mouth Rationale: A 4-month-old infant should be able to bring objects to her mouth.

8. A nurse is assessing a 15-month-old toddler. Which of the following findings should the nurse report to the provider? A. The toddler cannot build a tower of six to seven cubes. Rationale: The nurse should expect a 24-month-old toddler to be able to build a tower of six to seven cubes. B. The toddler cannot stand upright without support. Rationale: The nurse should expect a 15-month-old toddler to be able to stand upright without support. The nurse should report this finding to the provider as this can indicate a developmental delay. C. The toddler cannot jump with both feet. Rationale: The nurse should expect a 30-month-old toddler to be able to jump with both feet. D. The toddler cannot turn a doorknob. Rationale: The nurse should expect a 24-month-old toddler to be able to turn a doorknob.

9. A nurse is assessing a 10-month-old infant. Which of the following findings should the nurse report to the provider? A. The infant is unable to imitate animal sounds. Rationale: A 10-month-old infant should be able to verbalize "Dada," "Mama," and to comprehend the meaning of "Bye-bye." A 12-month-old infant should be able to imitate animal sounds. B. The infant does not sit steadily without support. Rationale: An 8-month-old infant should be able to sit steadily without support. A 10-month-old infant should be able to change from a prone to sitting position, stand while holding onto furniture, and lift one foot while standing. C. The infant cannot turn pages in a book. Rationale: A 12-month-old infant should be able to look at and follow pictures in a book. D. The infant cannot build a tower of three or four cubes. Rationale: An 18-month old toddler should be able to build a tower of three or four cubes.

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Detailed Answer Key Growth and Development: Infants and Toddlers 10.A nurse in a clinic is assessing a 7-month-old infant. Which of the following indicates a need for further evaluation? A. Uses a unidextrous grasp Rationale: A 7-month-old infant should exhibit a unidextrous approach and grasp; therefore, this does not indicate the need for further evaluation. B. Has a fear of strangers Rationale: A 7-month-old infant should exhibit a fear of strangers; therefore, this does not indicate the need for further evaluation. C. Shows preferences towards foods Rationale: A 7-month-old infant should exhibit a preference toward food likes and dislikes; therefore, this does not indicate the need for further evaluation. D. Babbles one-syllable sounds Rationale: A 7-month-old infant should babble in chained syllables such as mama and baba, and babble four distinct vowel sounds; therefore, this finding indicates a need for further evaluation.

11.A nurse is caring for a toddler. Which of the following statements should the nurse use when preparing to obtain the child's vital signs? A. "Can I listen to your lungs?" Rationale: The nurse should not ask yes/no questions. Negativism is exhibited by toddlers as a way of asserting self-control and gaining independence. Therefore, toddlers tend to answer questions with a negative response and are likely to initially resist attempts to measure their vital signs. If the nurse asks the question, the toddler responds "no," and the nurse proceeds anyway, it creates an environment of mistrust between the toddler and the nurse. B. "I am going to listen to your heart." Rationale: The nurse should inform the toddler of the procedure prior to taking vital signs. C. "I am going to take your blood pressure now." Rationale: The nurse should avoid using the word "take" when measuring vital signs. The toddler might interpret the words literally and think his blood pressure will be taken away from him. D. "Can you stand very still while I feel how warm you are?" Rationale: The nurse should not ask yes/no questions. Negativism is exhibited by toddlers as a way of asserting self-control and gaining independence. Therefore, toddlers tend to answer questions with a negative response and are likely to initially resist attempts to measure their vital signs. If the nurse asks the question, the toddler responds "no," and the nurse proceeds anyway, it creates an environment of mistrust between the toddler and the nurse.

12.A nurse is providing anticipatory guidance about child development to the parents of a toddler. Which of the

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Detailed Answer Key Growth and Development: Infants and Toddlers following developmental tasks should the nurse include as expected of a toddler? A. Explains the difference between right and wrong Rationale: Appropriate psychosocial development for a school-age child includes the ability to understand the difference between right and wrong. B. Prints letters and numbers Rationale: By 5 years of age, a preschooler's motor development should include the ability to print letters and numbers. C. Separates easily from primary care giver for short periods of time Rationale: By 3 years of age, a toddler's psychosocial development should include the ability to accept separating from a primary care giver for short periods of time. A toddler should also be able to express likes and dislikes and begin to play with children and others outside the family. D. Cooperates in doing simple chores Rationale: By 5 years of age, a preschooler's psychosocial development should include performing simple chores around the house, such as putting toys away and assisting with setting the table for meals.

13.A nurse is administering ear drops to a toddler and pulls the auricle down and back. The mother asks, "Why are you pulling the ear that way?" Which of the following explanations should the nurse provide? A. "This technique opens the ear canal, allowing medication to reach the inner ear region." Rationale: For children younger than 3 years old, the auricle should be pulled down and back to fully open the ear canal. This technique allows the correct dose of medication to enter the ear. B. "When this technique is used, the toddler experiences less pain." Rationale: This technique is used to open up the ear canal. Although it may be uncomfortable for the toddler, it should not be painful. To promote comfort, the nurse should warm the solution to room temperature prior to instillation. C. "This is the safest and easiest way to administer this medication." Rationale: Prior to age 3, ear drops should be administered using the technique of pulling the auricle down and back. After the age of 3, the auricle should be pulled up and back to facilitate administration of the correct dosage. D. "When this technique is used, the medication will not run out of the ear." Rationale: After the drops are in the ear, the nurse should gently place pressure on the small flap over the ear and have the child lie on her side. These actions prevent the medication from running back out of the canal.

14.A nurse is caring for a toddler who is having difficulty sleeping during hospitalization. Which of the following actions

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Detailed Answer Key Growth and Development: Infants and Toddlers should the nurse take to promote sleep? A. Explain the source of the toddler's fears. Rationale: Although a toddler's cognitive skills are developing rapidly, reasoning skills remain immature. Toddlers are aware of a causal relationship, such as turn on a light switch and light will appear. However, they are not able to transfer this knowledge to new situations. B. Turn off the room light. Rationale: Sleep disturbances are common and a night light is an appropriate intervention. During this developmental stage, fears can be provoked by stress, experiences of loss, or separation from parents. C. Provide bedtime rituals. Rationale: Establishing a bedtime routine is important. Reading a familiar book or providing a favorite stuffed toy or blanket will help decrease the child's insecurity and fears. D. Encourage play exercises in the evening. Rationale: Play allows children to express feelings and fears and is encouraged during hospitalization, but a child should have stimulating physical activity during the daytime, not in the evening before bedtime.

15.A nurse is providing health promotion teaching to the parents of a toddler. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Management of tantrums B. How to establish trust C. How to encourage cooperative play D. Dental care E. Need for increased caloric intake Rationale: Management of tantrums is correct. It is expected for toddlers to have temper tantrums.How to establish trust is incorrect. According to Erickson, establishing trust is the developmental goal associated with infancy.How to encourage cooperative play is incorrect. Toddlers engage in parallel play. Preschool-age children engage in cooperative play.Dental care is correct. Toddlers should be receiving dental care.Need for increased caloric intake is incorrect. The growth rate during the toddler years slows, which decreases the child's need for calories, protein, and fluid.

16.A nurse is collecting data from an infant at a well-child visit. The nurse should understand that birth weight typically doubles by what age? A. ?3 months Rationale:

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Detailed Answer Key Growth and Development: Infants and Toddlers Birth weight does not usually increase rapidly enough to double by 3 months of age. B. ?6 months Rationale: Birth weight typically doubles by 6 months of age. C. ?9 months Rationale: Birth usually doubles before 9 months of age. If birth weight has not doubled by this age, further investigation is warranted. D. ?12 months Rationale: Birth weight typically triples by 12 months of age.

17.A nurse is caring for a newborn whose mother voices concerns about sudden infant death syndrome (SIDS). The nurse should include which of the following statements in a discussion with the mother? A. "Placing your child on her back when sleeping will decrease the risk of SIDS." Rationale: The nurse should instruct the mother to position in the infant on her back during sleep to prevent SIDS. The incidence of SIDS has declined since the Back to Sleep campaign started in the 1990s. B. "SIDS is directly correlated with the diphtheria, tetanus, and pertussis vaccines." Rationale: There is no correlation between SIDS and diphtheria, tetanus, and pertussis vaccines. C. "SIDS rates have been rising over the last 10 years." Rationale: Mortality rates for SIDS have declined more than 50% in the U.S. since the 1990s. D. "Sleep apnea is the main cause of SIDS." Rationale: SIDS might be related to a brainstem abnormality in the neurologic regulation of cardiorespiratory control. Sleep apnea does not cause SIDS.

18.A nurse is caring for a 3-year-old child whose parents report that she has an intense fear of painful procedures, such as injections. Which of the following strategies should the nurse add to the child's plan of care? (Select all that apply.) A. Have a parent stay with the child during procedures. B. Cluster invasive procedures whenever possible. C. Perform the procedure as quickly as possible. D. Allow the child to keep a toy from home with her. E. Use mummy restraints during painful procedures. Rationale:

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Detailed Answer Key Growth and Development: Infants and Toddlers Have a parent stay with the child during procedures is correct. Maintaining parent-child contact is one of the most supportive interventions for toddlers and preschoolers undergoing painful procedures.Cluster invasive procedures when possible is incorrect. Clustering creates an unnecessarily lengthy and painful period for the client, which is likely to increase her fear.Perform procedures as quickly as possible is correct. Moving quickly through the steps of a painful procedure is a supportive intervention for children undergoing painful procedures.Allow the child to keep a toy from home with her is correct. Having familiar and cherished objects nearby is therapeutic for children during their hospitalization.Use mummy restraints during painful procedures is incorrect. Mummy restraints help to immobilize very young children and keep them safe during procedures, but it is likely to increase fear in toddlers and preschoolers.

19.A nurse is teaching a parent of a 6-month-old infant about car seat safety. Which of the following statements by the parent indicates an understanding of the teaching? A. "Our car seat is an infant model and is anchored in the car." Rationale: This statement by the parent indicates correct use of the infant care seat. B. "Our car seat is front-facing in the back seat." Rationale: The car seat should be rear-facing in the back seat of the car. C. "I can fit my hand between the baby and the car seat harness." Rationale: The parent should not be able to fit more than 2 fingers between the baby's chest and the car seat harness. D. "The car seat is rear-facing in the front passenger seat." Rationale: The car seat should be rear-facing in the back seat of the car.

20.A nurse teaching the parents of a 10-month-old infant about home safety. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Serve food in small, non-circular pieces. B. Tie plastic bags in knots before discarding them. C. Install accordion style gates. D. Set the water heater at 65...