PRACTICE
4TH EDITION
• AUTHOR(S)JEAN FORET
GIDDENS
TEST BANK
Question 1
Reference: Concept 1 — Development — Nursing Assessment &
Clinical Judgment
Stem: A nurse is conducting a well-child visit for a 4-month-old
infant. The parent reports the infant is smiling, cooing, and can
hold their head steady when pulled to a sitting position. The
infant does not yet roll over or reach for objects. Which nursing
action is most appropriate based on this developmental
assessment?
,Options:
A) Schedule a follow-up visit in one month to re-assess for
rolling.
B) Educate the parent on the importance of supervised tummy
time to strengthen muscles.
C) Refer the infant to a developmental specialist for further
evaluation.
D) Advise the parent to introduce solid foods to support
neurological growth.
Correct Answer: B) Educate the parent on the importance of
supervised tummy time to strengthen muscles.
Rationales:
• Correct: The infant’s skills are within normal
developmental expectations for 4 months. Tummy time
promotes strengthening of the neck, shoulder, and trunk
muscles, which are necessary for the next milestones of
rolling over and reaching. This is an appropriate, evidence-
based health promotion intervention.
• Incorrect A: A one-month follow-up is unnecessary as the
current findings are normal. Routine well-child visit
schedules are sufficient.
• Incorrect C: There is no indication for a developmental
referral. The infant’s achievements (social smile, cooing,
head control) are appropriate for age.
, • Incorrect D: Introducing solid foods is not developmentally
indicated at 4 months and is unrelated to the assessed
milestones. The American Academy of Pediatrics
recommends exclusive breastfeeding or formula until
about 6 months.
Teaching Point: Use validated developmental milestones to
screen for delays and provide anticipatory guidance to support
progression.
Citation: Giddens, J. F. (2025). Concepts for Nursing
Practice (4th ed.). Concept 1.
Question 2
Reference: Concept 1 — Development — Clinical Judgment &
Prioritization
Stem: A nurse in a pediatric clinic sees a 9-month-old who was
born at 28 weeks gestation. The parent is concerned the infant
is not crawling. Which action should the nurse take first when
assessing this infant's motor development?
Options:
A) Compare the infant’s skills to standard milestones for a 9-
month-old.
B) Calculate the infant’s corrected age and assess milestones
against that age.
C) Ask the parent to describe a typical day to observe for
, developmental red flags.
D) Assess the infant’s muscle tone and deep tendon reflexes.
Correct Answer: B) Calculate the infant’s corrected age and
assess milestones against that age.
Rationales:
• Correct: For preterm infants, developmental assessment
should use corrected age (chronological age minus the
number of weeks born early) until at least 2 years of age.
This is the first, most accurate step to determine expected
milestones.
• Incorrect A: Comparing to standard 9-month milestones
would be inaccurate and could lead to an inappropriate
concern for delay.
• Incorrect C: While a developmental history is important,
the nurse must first establish the correct age framework
for interpretation.
• Incorrect D: A neurological exam may be part of an
assessment, but it is not the priority first step before
accurately determining the infant's developmental age.
Teaching Point: Always use corrected age for developmental
assessment in preterm infants to avoid mislabeling a delay.
Citation: Giddens, J. F. (2025). Concepts for Nursing
Practice (4th ed.). Concept 1.