textbook 1st peds test
The nurse is examining a 10-month-old boy who was born 10 weeks early. Which of the following
findings is cause for concern?
A) The child has doubled his birthweight.
B) The child exhibits plantar grasp reflex.
C) The child's head circumference is 19.5 inches.
D) No primary teeth have erupted yet. - answer Ans: C
Feedback:
The child's head size is large for his adjusted age (7.5 months), which would be cause for concern.
Birth weight doubles by about 6 months of age. Plantar grasp reflex does not disappear until 9
months adjusted age. Primary teeth may not erupt until 8 months adjusted age.
The nurse is teaching a new mother about the drastic growth and developmental changes her infant
will experience in the first year of life. Which of the following describes a developmental milestone
occurring in infancy?
A) By 6 months of age the infant's brain weighs half that of the adult brain; at age 12 months, the
brain weighs 2.5 times what it did at birth.
B) Most infants triple their birthweight by 4 to 6 months of age and quadruple their birthweight by
the time they are 1 year old.
C) The head circumference increases rapidly during 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 rate decreases from 120 to
140 in the newborn to about 100 in the 1-year-old. - answer Ans: A
Feedback:
By 6 months of age the infant's brain weighs half that of the adult brain; at age 12 months, the brain
weighs 2.5 times what it did at birth. Most infants double their birthweight by 4 to 6 months of age
and triple their birthweight by the time they are 1 year old. The head circumference increases
rapidly during the first 6 months: the average increase is about 0.6 inch (1.5 cm) per month. The
heart doubles in size over the first year of life. As the cardiovascular system matures, the average
pulse rate decreases from 120 to 140 in the newborn to about 100 in the 1-year-old.
The nurse measures the head circumference of a 6-month-old infant. Which measurement would
the nurse interpret as most appropriate?
A) 33 cm
B) 35 cm
,C) 43.5 cm
D) 47 cm - answer Ans: C
Feedback:
Head circumference increases rapidly during the first 6 months. In a 6-month-old it is typically 42 to
44.5 cm (16.5 to 17.5 in); at birth it is usually 33 to 35 cm (13 to 14 in); and at 1 year of age it is
usually 45 to 47.5 cm (17.7 to 18.7 in).
The nurse is helping a new mother prepare for breastfeeding her infant. During which of the
following newborn states of consciousness would the nurse recommended attempting the feeding?
A) Light sleep
B) Drowsiness
C) Quiet alert state
D) Active alert state - answer Ans: C
Feedback:
A normal newborn will ordinarily move through six states of consciousness: (1) deep sleep: the
infant lies quietly without movement; (2) light sleep: the infant may move a little while sleeping and
may startle to noises; (3) drowsiness: eyes may close; the infant may be dozing; (4) quiet alert state:
the infant's eyes are open wide and the body is calm; (5) active alert state: the infant's face and body
move actively; and (6) crying: the infant cries or screams and the body moves in a disorganized
fashion. The quiet alert state is the optimal state in which to breastfeed an infant.
The nurse is assessing the respiratory system of a newborn. Which of the following anatomic
differences place the infant at risk for respiratory compromise? Select all answers that apply.
A) The nasal passages are narrower.
B) The trachea and chest wall are less compliant.
C) The bronchi and bronchioles are shorter and wider.
D) The larynx is more funnel shaped.
E) The tongue is smaller.
F) There are significantly fewer alveoli. - answer Ans: A, D, F
Feedback:
In comparison with the adult, in the infant, the nasal passages are narrower, the trachea and chest
wall are more compliant, the bronchi and bronchioles are shorter and narrower, the larynx is more
funnel shaped, the tongue is larger, and there are significantly fewer alveoli. These anatomic
differences place the infant at higher risk for respiratory compromise. The respiratory system does
not reach adult levels of maturity until about 7 years of age.
,A new mother shows the nurse that her baby grasps her finger when she touches the baby's palm.
How might the nurse respond to this information?
A) "This is a primitive reflex known as the plantar grasp."
B) "This is a primitive reflex known as the palmar grasp."
C) "This is a protective reflex known as rooting."
D) "This is a protective reflex known as the Moro reflex." - answer Ans: B
Feedback:
Primitive reflexes are subcortical and involve a whole-body response. Selected primitive reflexes
present at birth include Moro, root, suck, asymmetric tonic neck, plantar and palmar grasp, step, and
Babinski. During the palmar grasp, the infant reflexively grasps when the palm is touched. The
plantar grasp occurs when the infant reflexively grasps with the bottom of the foot when pressure is
applied to the plantar surface. The root reflex occurs when the infant's cheek is stroked and the
infant turns to that side, searching with mouth. The Moro reflex is displayed when with sudden
extension of the head, the arms abduct and move upward and the hands form a "C."
Which reflex, if found in a 4-month-old infant, would cause the nurse to be concerned?
A) Plantar grasp
B) Step
C) Babinski
D) Neck righting - answer Ans: B
Feedback:
Appropriate appearance and disappearance of primitive reflexes, along with the development of
protective reflexes, indicates a healthy neurologic system. The step reflex is a primitive reflex that
appears at birth and disappears at 4 to 8 weeks of age. The plantar grasp reflex 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 birth and disappears around the age of 12 months. The neck righting reflex is a
protective reflex that appears around the age of 4 to 6 months and persists.
A new mother expresses concern to the nurse that her baby is crying and grunting when passing
stool. What is the nurse's best response to this observation?
A) "This is normal behavior for infants unless the stool passed is hard and dry."
B) "This is normal behavior for infants due to the immaturity of the gastrointestinal system."
C) "This indicates a blockage in the intestine and must be reported to the physician."
D) "This is normal behavior for infants unless the stool passed is black or green." - answer Ans: A
, Feedback:
Due to the immaturity of the gastrointestinal system, newborns and young infants often grunt,
strain, or cry while attempting to have a bowel movement. This is not of concern unless the stool is
hard and dry. Stool color and texture may change depending on the foods that the infant is
ingesting. Iron supplements may cause the stool to appear black or very dark green.
The neonatal nurse assesses newborns for iron-deficiency anemia. Which of the following newborns
is at highest risk for this disorder?
A) A postterm newborn
B) A term newborn with jaundice
C) A newborn born to a diabetic mother
D) A premature newborn - answer Ans: D
Feedback:
Maternal iron stores are transferred to the fetus throughout the last trimester of pregnancy. Infants
born prematurely miss all or at least a portion of this iron store transfer, placing them at increased
risk for iron-deficiency anemia compared with term infants. An infant having jaundice, having been
born to a mother with diabetes, or have been born postterm does not significantly place the infant
at risk for iron-deficiency anemia.
The nurse caring for newborns knows that infants exhibit phenomenal increases in their gross motor
skills over the first 12 months of life. Which of the following statements accurately describe the
typical infant's achievement of these milestones? Select all answers that apply.
A) At 1 month the infant lifts and turns the head to the side in the prone position.
B) At 2 months the infant lifts head and looks around.
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 independently. - answer Ans: A, D, E, F
Feedback:
At 1 month the infant lifts and turns the head to the side in the prone position. At 7 months the
infant sits alone with some use of hands for support. At 9 months the infant crawls with the
abdomen off the floor. At 12 months the infant walks independently. At 4 months the infant lifts the
head and looks around. At 10 months the infant pulls to stand up.
At which age would the nurse expect to find the beginning of object permanence?
The nurse is examining a 10-month-old boy who was born 10 weeks early. Which of the following
findings is cause for concern?
A) The child has doubled his birthweight.
B) The child exhibits plantar grasp reflex.
C) The child's head circumference is 19.5 inches.
D) No primary teeth have erupted yet. - answer Ans: C
Feedback:
The child's head size is large for his adjusted age (7.5 months), which would be cause for concern.
Birth weight doubles by about 6 months of age. Plantar grasp reflex does not disappear until 9
months adjusted age. Primary teeth may not erupt until 8 months adjusted age.
The nurse is teaching a new mother about the drastic growth and developmental changes her infant
will experience in the first year of life. Which of the following describes a developmental milestone
occurring in infancy?
A) By 6 months of age the infant's brain weighs half that of the adult brain; at age 12 months, the
brain weighs 2.5 times what it did at birth.
B) Most infants triple their birthweight by 4 to 6 months of age and quadruple their birthweight by
the time they are 1 year old.
C) The head circumference increases rapidly during 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 rate decreases from 120 to
140 in the newborn to about 100 in the 1-year-old. - answer Ans: A
Feedback:
By 6 months of age the infant's brain weighs half that of the adult brain; at age 12 months, the brain
weighs 2.5 times what it did at birth. Most infants double their birthweight by 4 to 6 months of age
and triple their birthweight by the time they are 1 year old. The head circumference increases
rapidly during the first 6 months: the average increase is about 0.6 inch (1.5 cm) per month. The
heart doubles in size over the first year of life. As the cardiovascular system matures, the average
pulse rate decreases from 120 to 140 in the newborn to about 100 in the 1-year-old.
The nurse measures the head circumference of a 6-month-old infant. Which measurement would
the nurse interpret as most appropriate?
A) 33 cm
B) 35 cm
,C) 43.5 cm
D) 47 cm - answer Ans: C
Feedback:
Head circumference increases rapidly during the first 6 months. In a 6-month-old it is typically 42 to
44.5 cm (16.5 to 17.5 in); at birth it is usually 33 to 35 cm (13 to 14 in); and at 1 year of age it is
usually 45 to 47.5 cm (17.7 to 18.7 in).
The nurse is helping a new mother prepare for breastfeeding her infant. During which of the
following newborn states of consciousness would the nurse recommended attempting the feeding?
A) Light sleep
B) Drowsiness
C) Quiet alert state
D) Active alert state - answer Ans: C
Feedback:
A normal newborn will ordinarily move through six states of consciousness: (1) deep sleep: the
infant lies quietly without movement; (2) light sleep: the infant may move a little while sleeping and
may startle to noises; (3) drowsiness: eyes may close; the infant may be dozing; (4) quiet alert state:
the infant's eyes are open wide and the body is calm; (5) active alert state: the infant's face and body
move actively; and (6) crying: the infant cries or screams and the body moves in a disorganized
fashion. The quiet alert state is the optimal state in which to breastfeed an infant.
The nurse is assessing the respiratory system of a newborn. Which of the following anatomic
differences place the infant at risk for respiratory compromise? Select all answers that apply.
A) The nasal passages are narrower.
B) The trachea and chest wall are less compliant.
C) The bronchi and bronchioles are shorter and wider.
D) The larynx is more funnel shaped.
E) The tongue is smaller.
F) There are significantly fewer alveoli. - answer Ans: A, D, F
Feedback:
In comparison with the adult, in the infant, the nasal passages are narrower, the trachea and chest
wall are more compliant, the bronchi and bronchioles are shorter and narrower, the larynx is more
funnel shaped, the tongue is larger, and there are significantly fewer alveoli. These anatomic
differences place the infant at higher risk for respiratory compromise. The respiratory system does
not reach adult levels of maturity until about 7 years of age.
,A new mother shows the nurse that her baby grasps her finger when she touches the baby's palm.
How might the nurse respond to this information?
A) "This is a primitive reflex known as the plantar grasp."
B) "This is a primitive reflex known as the palmar grasp."
C) "This is a protective reflex known as rooting."
D) "This is a protective reflex known as the Moro reflex." - answer Ans: B
Feedback:
Primitive reflexes are subcortical and involve a whole-body response. Selected primitive reflexes
present at birth include Moro, root, suck, asymmetric tonic neck, plantar and palmar grasp, step, and
Babinski. During the palmar grasp, the infant reflexively grasps when the palm is touched. The
plantar grasp occurs when the infant reflexively grasps with the bottom of the foot when pressure is
applied to the plantar surface. The root reflex occurs when the infant's cheek is stroked and the
infant turns to that side, searching with mouth. The Moro reflex is displayed when with sudden
extension of the head, the arms abduct and move upward and the hands form a "C."
Which reflex, if found in a 4-month-old infant, would cause the nurse to be concerned?
A) Plantar grasp
B) Step
C) Babinski
D) Neck righting - answer Ans: B
Feedback:
Appropriate appearance and disappearance of primitive reflexes, along with the development of
protective reflexes, indicates a healthy neurologic system. The step reflex is a primitive reflex that
appears at birth and disappears at 4 to 8 weeks of age. The plantar grasp reflex 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 birth and disappears around the age of 12 months. The neck righting reflex is a
protective reflex that appears around the age of 4 to 6 months and persists.
A new mother expresses concern to the nurse that her baby is crying and grunting when passing
stool. What is the nurse's best response to this observation?
A) "This is normal behavior for infants unless the stool passed is hard and dry."
B) "This is normal behavior for infants due to the immaturity of the gastrointestinal system."
C) "This indicates a blockage in the intestine and must be reported to the physician."
D) "This is normal behavior for infants unless the stool passed is black or green." - answer Ans: A
, Feedback:
Due to the immaturity of the gastrointestinal system, newborns and young infants often grunt,
strain, or cry while attempting to have a bowel movement. This is not of concern unless the stool is
hard and dry. Stool color and texture may change depending on the foods that the infant is
ingesting. Iron supplements may cause the stool to appear black or very dark green.
The neonatal nurse assesses newborns for iron-deficiency anemia. Which of the following newborns
is at highest risk for this disorder?
A) A postterm newborn
B) A term newborn with jaundice
C) A newborn born to a diabetic mother
D) A premature newborn - answer Ans: D
Feedback:
Maternal iron stores are transferred to the fetus throughout the last trimester of pregnancy. Infants
born prematurely miss all or at least a portion of this iron store transfer, placing them at increased
risk for iron-deficiency anemia compared with term infants. An infant having jaundice, having been
born to a mother with diabetes, or have been born postterm does not significantly place the infant
at risk for iron-deficiency anemia.
The nurse caring for newborns knows that infants exhibit phenomenal increases in their gross motor
skills over the first 12 months of life. Which of the following statements accurately describe the
typical infant's achievement of these milestones? Select all answers that apply.
A) At 1 month the infant lifts and turns the head to the side in the prone position.
B) At 2 months the infant lifts head and looks around.
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 independently. - answer Ans: A, D, E, F
Feedback:
At 1 month the infant lifts and turns the head to the side in the prone position. At 7 months the
infant sits alone with some use of hands for support. At 9 months the infant crawls with the
abdomen off the floor. At 12 months the infant walks independently. At 4 months the infant lifts the
head and looks around. At 10 months the infant pulls to stand up.
At which age would the nurse expect to find the beginning of object permanence?
