NSG 434 Nursing Care of Children | Grand
Canyon University
1. A nurse is assessing a 6-month-old infant during a well-child visit. If the infant’s birth
weight was 3.2 kg (7 lbs), which weight should the nurse expect now?
A. 4.8 kg (10.5 lbs)
B. 9.6 kg (21 lbs)
C. 6.4 kg (14 lbs)
D. 12.8 kg (28 lbs)
Answer: C
Rationale: Typically, an infant’s birth weight doubles by the age of 5 to 6 months. Since the
starting weight was 3.2 kg, the nurse should expect the infant to weigh approximately 6.4
kg. Consistent weight gain is a primary indicator of adequate nutritional intake and general
health in infants.
2. In what order should a nurse perform a physical examination on a 2-year-old child to
ensure cooperation?
A. Head-to-toe assessment regardless of the child’s mood
B. Invasive procedures like ear and throat exams first
C. Least invasive to most invasive procedures
,D. Vitals signs first, followed by abdominal palpation
Answer: C
Rationale: For toddlers, performing the least invasive procedures first helps to build trust
and reduce fear. Saving intrusive assessments, such as examining the throat or ears, for the
end of the exam prevents the child from becoming distressed too early. This strategic
approach allows the nurse to collect accurate data like heart and lung sounds while the
child is calm.
3. A 10-month-old infant is crying and clinging to their parent when the nurse enters the
room. Which developmental milestone is this infant likely exhibiting?
A. Regression
B. Autonomy
C. Stranger anxiety
D. Temper tantrum
Answer: C
Rationale: Stranger anxiety typically develops between 6 and 8 months of age and peaks
around 10 months. It is a normal developmental stage indicating that the infant can
distinguish between familiar and unfamiliar caregivers. Nurses should approach the infant
slowly and allow the parent to hold the child during the assessment to provide comfort.
, 4. According to Erikson’s theory, which psychosocial stage is a preschool-aged child (3-6
years) currently navigating?
A. Trust vs. Mistrust
B. Autonomy vs. Shame and Doubt
C. Initiative vs. Guilt
D. Industry vs. Inferiority
Answer: C
Rationale: Preschoolers are in the Initiative vs. Guilt stage, where they begin to assert
power and control over their environment through play. Successful completion of this stage
leads to a sense of purpose and leadership skills. If children are discouraged from
exploring, they may develop a sense of guilt regarding their actions.
5. At what age should the nurse expect the anterior fontanel of an infant to be completely
closed?
A. 2 to 3 months
B. 6 to 8 months
C. 12 to 18 months
D. 24 to 30 months
Answer: C