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1. The nurse is assessing a 2-year-old child. Which
finding would be a cause for concern?
A. Weight of 26 pounds
B. Head circumference equal to chest circumference
C. Anterior fontanel not fully closed
D. Height of 34 inches
Correct Answer: C. Rationale: The anterior fontanel
typically closes between 12 and 18 months of age.
Failure of the anterior fontanel to close by 2 years of
age is a developmental delay and requires further
,assessment. Weight, height, and head
circumference proportional to chest circumference
are expected findings for this age.
2. The nurse is preparing to administer an oral
liquid medication to a 9-month-old infant. Which
action is most appropriate?
A. Administer the medication with a cup so the
infant can practice self-feeding.
B. Mix the medication with a full bottle of formula
to ensure it is consumed.
C. Use an oral syringe to gently squirt the
medication into the side of the cheek.
D. Place the medication in a feeding syringe and
squirt it directly to the back of the throat.
Correct Answer: C. Rationale: Using an oral syringe
to administer medication into the side of the cheek
(buccal area) allows for controlled administration
and reduces the risk of aspiration. This method is
safe and effective for infants. Medications should
not be mixed with a full bottle of formula as the
,infant may not consume the entire volume, and a
cup is not appropriate for a 9-month-old.
3. The mother of a 6-year-old child with otitis
media asks when her child can return to school.
The nurse's best response is based on the
understanding that:
A. The child can return 24 hours after antibiotic
therapy has been initiated.
B. The child must complete the full course of
antibiotics before returning to school.
C. The child can return when the fever has resolved
and the child feels well.
D. The child must be afebrile for 48 hours before
returning to school.
Correct Answer: C. Rationale: The primary concern
for school attendance is the child's ability to
participate in learning and the risk of transmission.
With appropriate antibiotic therapy, the child is
generally considered non-contagious within 24
hours, but the most important criterion is that the
, child is afebrile and feeling well enough to resume
normal activities.
4. The nurse is providing anticipatory guidance to
the parents of a 12-month-old infant. Which gross
motor skill should the nurse expect the infant to
have achieved?
A. Walking alone without support.
B. Standing independently.
C. Walking while holding onto furniture.
D. Crawling up the stairs.
Correct Answer: B. Rationale: By 12 months of age,
an infant should be able to stand independently for
a brief moment. Walking independently is an 18-
month milestone, and while a 12-month-old may
cruise, they are expected to stand alone.
5. A parent reports that their preschool-aged child
has a "barking" cough that is worse at night and is
accompanied by stridor. Based on these
symptoms, the nurse suspects the child has:
A. Asthma.
B. Bronchiolitis.