Q&A
1. A nurse is preparing to administer a vaccine to a 2-month-old infant. Which
vaccine is typically administered at this age?
A) MMR
B) Varicella
C) DTaP
D) Hepatitis A
Correct Answer: DTaP
Rationale: The DTaP (diphtheria, tetanus, and acellular pertussis) vaccine is
administered at 2, 4, and 6 months of age. MMR and varicella are given at 12-15
months, and Hepatitis A is given at 12 months. Following the recommended
immunization schedule is critical for preventing serious communicable diseases.
2. A 6-month-old infant is brought to the clinic for a routine well-child visit. The
nurse notes that the infant can roll from back to abdomen, sit with tripod support,
and transfer objects from hand to hand. Which additional milestone is expected at
this age?
A) Pulling to a standing position
B) Walking independently
C) Mature pincer grasp
D) Babbling and laughing aloud
Correct Answer: Babbling and laughing aloud
,Rationale: At 6 months, typical milestones include rolling over, sitting with support,
transferring objects, and vocalizations such as babbling and laughing aloud. Pulling
to stand and walking occur later, and a mature pincer grasp develops around 9-10
months.
3. A nurse is teaching parents about injury prevention for their toddler. Which
intervention is most important to prevent poisoning?
A) Keeping medications in child-resistant containers
B) Storing cleaning supplies in a locked cabinet
C) Having the Poison Control number readily available
D) All of the above
Correct Answer: All of the above
Rationale: Poisoning prevention requires multiple strategies: child-resistant
containers, locked cabinets for hazardous substances, and immediate access to the
Poison Control number. Toddlers are exploratory and at high risk for accidental
ingestion, making a comprehensive approach essential.
4. A 2-year-old toddler is evaluated for delayed speech. The child uses approximately
10 single words and does not combine two words. What is the most appropriate
nursing action?
A) Reassure the parents and schedule a follow-up in one year
B) Order an immediate brain MRI
C) Refer for formal speech-language evaluation and developmental screening
D) Initiate high-dose vitamin supplementation
Correct Answer: Refer for formal speech-language evaluation and developmental
screening
, Rationale: By 24 months, a toddler should have a vocabulary of at least 50 words
and be combining two-word phrases. A vocabulary of only 10 words warrants early
intervention and formal developmental screening to address potential speech delay.
5. A 4-year-old child presents with a 3-hour history of high fever, severe drooling,
muffled voice, and stridor in a tripod position. The child appears anxious and toxic.
What is the priority nursing action?
A) Perform a direct oral examination with a tongue depressor
B) Obtain stat blood cultures with the child lying flat
C) Ensure immediate airway stabilization and avoid invasive throat exams
D) Administer oral cough suppressants and discharge home
Correct Answer: Ensure immediate airway stabilization and avoid invasive throat
exams
Rationale: These findings are classic for acute epiglottitis, a life-threatening
emergency. Airway stabilization is the priority, and invasive throat exams should be
avoided as they can precipitate complete airway obstruction.
6. A nurse is assessing an infant for signs of developmental dysplasia of the hip
(DDH). Which finding is most consistent with this condition?
A) Symmetrical gluteal folds
B) Positive Ortolani sign
C) Full range of motion in both hips
D) Negative Barlow test
Correct Answer: Positive Ortolani sign