SAUNDERS COMPREHENSIVE REVIEW FOR THE NCLEX-
PN® EXAMINATION
9TH EDITION
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
PEDIATRIC NURSING (CHILD HEALTH & DEVELOPMENTAL
DISORDERS) TEST BANK
Questions
1. (Milestone identification — 2 months)
A nurse is assessing a 2-month-old infant for developmental
milestones during a well-child visit. Which finding is most
appropriate for this age?
A. Cruises around furniture.
B. Begins to use 2-word phrases.
C. Demonstrates a social (reciprocal) smile and follows objects
past midline.
D. Copies a circle and hops on one foot.
Correct answer: C
,Rationale:
• Correct (C): At ~2 months infants commonly show a social
or reciprocal smile and track objects past midline — these
are expected early social and visual tracking milestones
(CDC milestones). This supports the nurse’s assessment
and age-appropriate anticipatory guidance. CDC
• Incorrect (A): Cruising (walking while holding furniture) is
characteristic of later infancy/toddler transition (around 9–
12 months); not expected at 2 months.
• Incorrect (B): Using 2-word phrases is typically seen
around 2 years; not an infant milestone.
• Incorrect (D): Copying a circle and hopping are preschool
motor skills (around age 4–5 years). Selecting these would
reflect an inaccurate developmental expectation and could
lead to missed screening or incorrect teaching.
2. (Milestone — 6 months)
Which developmental skill would the pediatric nurse expect a 6-
month-old to demonstrate?
A. Sits with minimal support and transfers objects hand-to-
hand.
B. Tells a short story with full sentences.
C. Dresses self independently.
D. Rides a tricycle.
Correct answer: A
,Rationale:
• Correct (A): By ~6 months most infants can sit with little or
no support and can transfer objects from one hand to the
other — gross and fine motor milestones appropriate for
developmental surveillance (CDC). CDC
• Incorrect (B): Telling a short story with sentences is a
preschool language skill (≈4–5 years).
• Incorrect (C): Independent dressing is a later milestone
(toddler/preschool years).
• Incorrect (D): Riding a tricycle is usually seen around 3
years. Choosing these distractors would reflect unrealistic
expectations and could prompt unnecessary referrals.
3. (Milestone — 2 years / safety)
During a 2-year well visit, a parent reports the child uses many
single words but not two-word phrases. The nurse’s best
response is:
A. “That’s expected — two-word phrases typically appear
around 2 years; continue to monitor and encourage talking.”
B. “This is a severe delay — schedule immediate referral for
speech therapy and audiology today.”
C. “Your child will outgrow it; no further action needed.”
D. “Stop worrying; children speak when they are ready.”
Correct answer: A
, Rationale:
• Correct (A): Two-word phrases commonly emerge by ~2
years. The appropriate nursing response acknowledges
developmental norms, provides teaching/anticipatory
guidance and encourages language stimulation; it also sets
a plan for monitoring and referral if concerns persist. CDC
milestones guide this approach. CDC
• Incorrect (B): Immediate automatic referral without
assessment is excessive; a stepwise approach (screening,
monitor, refer if delayed) is safer and more aligned with
guidelines.
• Incorrect (C): Saying “no further action” ignores the need
for surveillance — if child is at risk or regression occurs,
screening/referral may be needed.
• Incorrect (D): Dismissing the parent’s concern is
nontherapeutic and undermines trust; nurses should
provide clear guidance.
4. (Respiratory — asthma acute care)
A 7-year-old with known moderate persistent asthma arrives
with audible wheeze, retractions, and tachypnea. After
assessing airway and breathing, the nurse’s priority intervention
is:
A. Administer prescribed short-acting beta2 agonist via
metered-dose inhaler with spacer.
PN® EXAMINATION
9TH EDITION
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
PEDIATRIC NURSING (CHILD HEALTH & DEVELOPMENTAL
DISORDERS) TEST BANK
Questions
1. (Milestone identification — 2 months)
A nurse is assessing a 2-month-old infant for developmental
milestones during a well-child visit. Which finding is most
appropriate for this age?
A. Cruises around furniture.
B. Begins to use 2-word phrases.
C. Demonstrates a social (reciprocal) smile and follows objects
past midline.
D. Copies a circle and hops on one foot.
Correct answer: C
,Rationale:
• Correct (C): At ~2 months infants commonly show a social
or reciprocal smile and track objects past midline — these
are expected early social and visual tracking milestones
(CDC milestones). This supports the nurse’s assessment
and age-appropriate anticipatory guidance. CDC
• Incorrect (A): Cruising (walking while holding furniture) is
characteristic of later infancy/toddler transition (around 9–
12 months); not expected at 2 months.
• Incorrect (B): Using 2-word phrases is typically seen
around 2 years; not an infant milestone.
• Incorrect (D): Copying a circle and hopping are preschool
motor skills (around age 4–5 years). Selecting these would
reflect an inaccurate developmental expectation and could
lead to missed screening or incorrect teaching.
2. (Milestone — 6 months)
Which developmental skill would the pediatric nurse expect a 6-
month-old to demonstrate?
A. Sits with minimal support and transfers objects hand-to-
hand.
B. Tells a short story with full sentences.
C. Dresses self independently.
D. Rides a tricycle.
Correct answer: A
,Rationale:
• Correct (A): By ~6 months most infants can sit with little or
no support and can transfer objects from one hand to the
other — gross and fine motor milestones appropriate for
developmental surveillance (CDC). CDC
• Incorrect (B): Telling a short story with sentences is a
preschool language skill (≈4–5 years).
• Incorrect (C): Independent dressing is a later milestone
(toddler/preschool years).
• Incorrect (D): Riding a tricycle is usually seen around 3
years. Choosing these distractors would reflect unrealistic
expectations and could prompt unnecessary referrals.
3. (Milestone — 2 years / safety)
During a 2-year well visit, a parent reports the child uses many
single words but not two-word phrases. The nurse’s best
response is:
A. “That’s expected — two-word phrases typically appear
around 2 years; continue to monitor and encourage talking.”
B. “This is a severe delay — schedule immediate referral for
speech therapy and audiology today.”
C. “Your child will outgrow it; no further action needed.”
D. “Stop worrying; children speak when they are ready.”
Correct answer: A
, Rationale:
• Correct (A): Two-word phrases commonly emerge by ~2
years. The appropriate nursing response acknowledges
developmental norms, provides teaching/anticipatory
guidance and encourages language stimulation; it also sets
a plan for monitoring and referral if concerns persist. CDC
milestones guide this approach. CDC
• Incorrect (B): Immediate automatic referral without
assessment is excessive; a stepwise approach (screening,
monitor, refer if delayed) is safer and more aligned with
guidelines.
• Incorrect (C): Saying “no further action” ignores the need
for surveillance — if child is at risk or regression occurs,
screening/referral may be needed.
• Incorrect (D): Dismissing the parent’s concern is
nontherapeutic and undermines trust; nurses should
provide clear guidance.
4. (Respiratory — asthma acute care)
A 7-year-old with known moderate persistent asthma arrives
with audible wheeze, retractions, and tachypnea. After
assessing airway and breathing, the nurse’s priority intervention
is:
A. Administer prescribed short-acting beta2 agonist via
metered-dose inhaler with spacer.
