NURS 420 EXAM 1 QUESTIONS AND ANSWERS
The nurse is assessing the respiratory system of a newborn. Which anatomic differences place the infant
at risk for respiratory compromise? Select all 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. - CORRECT ANSWER✅✅Answers:
-The nasal passages are narrower
-The larynx is more funnel-shaped
-There are significantly fewer alveoli
Rationale: 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.
At which age would the nurse expect to find the beginning of object permanence?
a. 1 month
b. 6 months
c. 9 months
d. 12 months - CORRECT ANSWER✅✅Answer: 6 months
,Rationale:
Object permanence begins to develop between 4 and 7 months of age and is solidified by approximately
age 8 months. By age 12 months, the infant knows he or she is separate from the parent or caregiver.
The nurse caring for newborns knows that infants exhibit phenomenal increases in their gross motor
skills over the first 12 months of life. Which statements accurately describe the typical infant's
achievement of these milestones? Select all 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 rolls from supine to prone to back again.
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. - CORRECT ANSWER✅✅Answers:
a. At 1 month, the infant lifts and turns the head to the side in the prone position.
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.
Rationale: 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.
The nurse observes an infant interacting with his parents. What are normal social behavioral
developments for this age group? Select all that apply.
a. Around 5 months, the infant may develop stranger anxiety.
b. Around 2 months, the infant exhibits a first real smile.
,c. Around 3 months, the infant smiles widely and gurgles when interacting with the caregiver.
d. Around 3 months, the infant will mimic the parent's facial movements, such as sticking out the
tongue.
e. Around 3 to 6 months of age, the infant may enjoy socially interactive games such as patty-cake and
peek-a-boo.
f. Separation anxiety may also start in the last few months of infancy. - CORRECT ANSWER✅✅Answers:
b. Around 2 months, the infant exhibits a first real smile.
c. Around 3 months, the infant smiles widely and gurgles when interacting with the caregiver.
d. Around 3 months, the infant will mimic the parent's facial movements, such as sticking out the
tongue.
f. Separation anxiety may also start in the last few months of infancy.
Rationale: The infant exhibits a first real smile at age 2 months. By about 3 months of age, the infant will
start an interaction with a caregiver by smiling widely and possibly gurgling. The 3- to 4-month-old will
also mimic the parent's facial movements, such as widening the eyes and sticking out the tongue.
Separation anxiety may also start in the last few months of infancy. Around the age of 8 months, the
infant may develop stranger anxiety. At 6 to 8 months of age, the infant may enjoy socially interactive
games such as patty-cake and peek-a-boo.
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." - CORRECT ANSWER✅✅Answer: "This is a
primitive reflex known as the palmar grasp."
, 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 - CORRECT ANSWER✅✅Answer: Step
Rationale: 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 healthcare provider."
d. "This is normal behavior for infants unless the stool passed is black or green." - CORRECT
ANSWER✅✅Answer: "This is normal behavior for infants unless the stool passed is hard and dry."
The nurse is assessing the respiratory system of a newborn. Which anatomic differences place the infant
at risk for respiratory compromise? Select all 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. - CORRECT ANSWER✅✅Answers:
-The nasal passages are narrower
-The larynx is more funnel-shaped
-There are significantly fewer alveoli
Rationale: 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.
At which age would the nurse expect to find the beginning of object permanence?
a. 1 month
b. 6 months
c. 9 months
d. 12 months - CORRECT ANSWER✅✅Answer: 6 months
,Rationale:
Object permanence begins to develop between 4 and 7 months of age and is solidified by approximately
age 8 months. By age 12 months, the infant knows he or she is separate from the parent or caregiver.
The nurse caring for newborns knows that infants exhibit phenomenal increases in their gross motor
skills over the first 12 months of life. Which statements accurately describe the typical infant's
achievement of these milestones? Select all 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 rolls from supine to prone to back again.
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. - CORRECT ANSWER✅✅Answers:
a. At 1 month, the infant lifts and turns the head to the side in the prone position.
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.
Rationale: 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.
The nurse observes an infant interacting with his parents. What are normal social behavioral
developments for this age group? Select all that apply.
a. Around 5 months, the infant may develop stranger anxiety.
b. Around 2 months, the infant exhibits a first real smile.
,c. Around 3 months, the infant smiles widely and gurgles when interacting with the caregiver.
d. Around 3 months, the infant will mimic the parent's facial movements, such as sticking out the
tongue.
e. Around 3 to 6 months of age, the infant may enjoy socially interactive games such as patty-cake and
peek-a-boo.
f. Separation anxiety may also start in the last few months of infancy. - CORRECT ANSWER✅✅Answers:
b. Around 2 months, the infant exhibits a first real smile.
c. Around 3 months, the infant smiles widely and gurgles when interacting with the caregiver.
d. Around 3 months, the infant will mimic the parent's facial movements, such as sticking out the
tongue.
f. Separation anxiety may also start in the last few months of infancy.
Rationale: The infant exhibits a first real smile at age 2 months. By about 3 months of age, the infant will
start an interaction with a caregiver by smiling widely and possibly gurgling. The 3- to 4-month-old will
also mimic the parent's facial movements, such as widening the eyes and sticking out the tongue.
Separation anxiety may also start in the last few months of infancy. Around the age of 8 months, the
infant may develop stranger anxiety. At 6 to 8 months of age, the infant may enjoy socially interactive
games such as patty-cake and peek-a-boo.
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." - CORRECT ANSWER✅✅Answer: "This is a
primitive reflex known as the palmar grasp."
, 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 - CORRECT ANSWER✅✅Answer: Step
Rationale: 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 healthcare provider."
d. "This is normal behavior for infants unless the stool passed is black or green." - CORRECT
ANSWER✅✅Answer: "This is normal behavior for infants unless the stool passed is hard and dry."
