100% Correct Answers & Rationales
Question 1
A nurse is assessing a 4-month-old infant during a routine well-child visit. Which
developmental milestone should the nurse expect the infant to demonstrate?
A. Sitting unsupported with a straight back
B. Displaying complete absence of head lag when pulled to a sitting position
C. Using a neat pincer grasp to pick up small objects
D. Rolling completely from back to abdomen
Correct Answer:
B. Displaying complete absence of head lag when pulled to a sitting position
Rationale:
Complete resolution of head lag is expected by 4 months of age as neck flexor
muscles strengthen. Persistent head lag beyond 4 to 6 months suggests motor
developmental delay or cerebral palsy. Rolling back to front and sitting
unsupported occur later, around 5 to 7 months.
Question 2
A nurse is assessing an 8-month-old infant. Which fine motor activity should the
nurse expect the infant to perform successfully?
,A. Stacking a tower of three wooden blocks
B. Transferring a small toy from one hand to the other
C. Scribbling spontaneously with a large crayon
D. Turning the pages of a board book one by one
Correct Answer:
B. Transferring a small toy from one hand to the other
Rationale:
Transferring objects between hands is an expected 7- to 8-month fine motor
milestone reflecting emerging bilateral coordination. Stacking blocks and
scribbling develop between 15 and 18 months, while turning individual book
pages typically occurs in toddlerhood around 24 months of age.
Question 3
A nurse is providing dietary guidance to the parents of a 6-month-old infant.
Which feeding instruction should the nurse include?
A. Introduce whole cow's milk as a primary beverage
B. Introduce single-ingredient foods one at a time, spaced 4 to 7 days apart
C. Add pureed meats to the infant's formula bottle
D. Give 1 teaspoon of honey daily to sweeten infant cereal
Correct Answer:
B. Introduce single-ingredient foods one at a time, spaced 4 to 7 days apart
Rationale:
Spacing single-ingredient solid foods 4 to 7 days apart allows parents to isolate
,and identify food allergens or intolerances. Honey is strictly contraindicated in
infants under 12 months due to infant botulism risk, and whole cow's milk lacks
sufficient bioavailable iron and vitamins.
Question 4
A nurse is assessing a 12-month-old infant whose birth weight was 8 pounds (3.6
kg). Which weight measurement indicates expected physical growth?
A. 16 pounds (7.2 kg)
B. 24 pounds (10.8 kg)
C. 32 pounds (14.4 kg)
D. 40 pounds (18.1 kg)
Correct Answer:
B. 24 pounds (10.8 kg)
Rationale:
An infant's birth weight is expected to double by 5 to 6 months and triple by 12
months of age. For an infant born at 8 pounds, tripling the birth weight yields an
expected 1-year weight of approximately 24 pounds (10.8 kg).
Question 5
A nurse is observing the play behaviors of several 2-year-old toddlers in a
clinical daycare setting. Which type of play should the nurse recognize as
developmentally expected?
, A. Solitary play without awareness of other children
B. Parallel play alongside peers using similar toys without direct interaction
C. Cooperative play with assigned rules and shared goals
D. Associative play involving mutual dramatic role-playing
Correct Answer:
B. Parallel play alongside peers using similar toys without direct interaction
Rationale:
Toddlers engage in parallel play, playing side-by-side with similar toys without
interacting or sharing goals. Solitary play is characteristic of infants, associative
play is typical of preschoolers, and cooperative, rule-governed play emerges
during the school-age years.
Question 6
A nurse is teaching the parents of a 2-year-old toddler how to manage frequent
temper tantrums. Which strategy should the nurse recommend?
A. Reason with the child verbally during the height of the emotional outburst
B. Ensure the immediate physical environment is safe and ignore the attention-
seeking behavior
C. Concede to the child's original demand to calm the behavior
D. Place the child in a dark, isolated room for 30 minutes
Correct Answer:
B. Ensure the immediate physical environment is safe and ignore the attention-
seeking behavior