PRACTICE QUESTIONS COMPLETE WITH CORRECT
ANSWERS & EXPLANATIONS
1. A mother expresses concern that her 4-month-old infant still has a prominent
startle (Moro) reflex. What is the most appropriate nursing response?
A. "This is a normal finding that should disappear by 6 months of age."
B. "We should schedule a neurological consult immediately."
C. "This reflex typically integrates by 4 months, so it is slightly delayed."
D. "The reflex should have integrated by 2 months; we need to monitor closely."
Correct Answer: A. The Moro reflex is present at birth and typically integrates
(disappears) by 6 months of age. Therefore, it is normal to still be present at 4
months.
2. A 16-year-old male is concerned because one testicle hangs lower than the
other. What is the best action by the nurse?
A. Refer the patient to a urologist for suspected torsion.
B. Reassure the patient that this is a normal anatomical variation.
C. Palpate the inguinal canal to check for an undescended testicle.
D. Prepare the patient for an ultrasound to rule out a tumor.
Correct Answer: B. It is normal for one testicle (usually the left) to hang lower
than the other to prevent them from compressing each other. This is not a sign of
torsion, undescended testes, or tumor.
3. According to Piaget, what is the primary developmental task of the
sensorimotor stage?
A. Developing logical thought and abstract reasoning.
,B. Mastering the concept of conservation.
C. Understanding the world through senses and motor actions.
D. Developing the ability to think hypothetically.
Correct Answer: C. The sensorimotor stage (birth to 2 years) is characterized by
infants learning about their environment through their senses and motor activities
(looking, touching, mouthing). Abstract reasoning and conservation come later.
4. A 7-year-old child is brought to the clinic for a routine check-up. The nurse
notes that the child is unable to distinguish right from left. What is the most
appropriate action?
A. Refer the child for a complete neurological evaluation.
B. Document the finding as a normal developmental milestone for this age.
C. Ask the child to draw a person to assess for cognitive delays.
D. Suggest the parents practice this skill daily as the child is behind.
Correct Answer: B. The ability to distinguish right from left typically develops
between 7 and 9 years of age. A 7-year-old is at the beginning of this
developmental stage, so it is not yet a consistent skill.
5. Which of the following immunizations is recommended to be given at birth?
A. DTaP (Diphtheria, Tetanus, Pertussis)
B. MMR (Measles, Mumps, Rubella)
C. Hepatitis B
D. Varicella (Chickenpox)
Correct Answer: C. The Hepatitis B vaccine is the only vaccine routinely
recommended for administration at birth. The others are given later (e.g., DTaP at
2 months, MMR at 12-15 months).
6. A parent is concerned that their 2-year-old toddler is not sharing toys with
other children. Based on developmental theories, what is the best explanation
for this behavior?
A. The child is demonstrating typical egocentric behavior for this age.
B. This behavior indicates a potential for a conduct disorder.
C. The child is showing early signs of autism spectrum disorder.
D. The parent has not properly enforced rules about sharing.
,Correct Answer: A. According to Piaget, toddlers in the preoperational stage are
egocentric; they cannot see the world from another's point of view. Sharing
requires an understanding of another's needs, which is beyond a 2-year-old's
cognitive development.
7. A 14-year-old girl has just received her first period (menarche). What is the
most appropriate nursing assessment regarding this event?
A. Evaluate her for precocious puberty, as this is earlier than expected.
B. Assess her readiness and knowledge about menstrual hygiene and
reproduction.
C. Teach her that she will now have a regular 28-day cycle every month.
D. Refer her to an endocrinologist for early hormonal evaluation.
Correct Answer: B. The average age of menarche is 12-13 years, so 14 is within
the normal range. The priority is to assess her physical and emotional readiness
and provide education. Cycles are often irregular for the first 1-2 years.
8. During a well-child visit, the nurse assesses a 9-month-old infant for pincer
grasp. What is the nurse looking for?
A. The infant grasping a rattle with the whole hand.
B. The infant using the thumb and forefinger to pick up a small object.
C. The infant transferring an object from one hand to the other.
D. The infant holding a bottle using both hands.
Correct Answer: B. The pincer grasp is the ability to pick up a small object using
the tips of the thumb and index finger. This is a fine motor skill that typically
develops around 9-10 months of age.
9. Which theorist is best known for the "Strange Situation" experiment, which is
used to assess attachment styles in infants?
A. Jean Piaget
B. Erik Erikson
C. John Bowlby
D. Mary Ainsworth
Correct Answer: D. Mary Ainsworth developed the "Strange Situation" procedure
to observe early emotional attachment between a child and their caregiver.
, Bowlby developed the theory of attachment, but Ainsworth developed the
assessment tool.
10. A mother states she is starting her 6-month-old on pureed foods. What is the
most important instruction for the nurse to provide regarding introducing new
foods?
A. Introduce only one new food every 3-5 days to watch for allergic reactions.
B. Start with honey and cereal to build a healthy immune system.
C. Introduce vegetables before fruits to prevent a sweet tooth.
D. Mix all new foods together to get the infant used to different tastes.
Correct Answer: A. Introducing one single-ingredient food at a time and waiting 3-
5 days allows the parent to identify any allergic reaction or intolerance to that
specific food. Honey is contraindicated under 1 year due to botulism risk.
11. A 5-year-old child in the preoperational stage of development is asked, "Do
you have a brother?" The child says "Yes." When asked, "Does your brother
have a sister?" the child says "No." Which concept best explains this response?
A. Animism
B. Egocentrism
C. Reversibility
D. Conservation
Correct Answer: B. The child’s inability to understand that the brother also has a
sister is due to egocentrism. The child cannot take the perspective of the brother.
Reversibility and conservation are logical thinking abilities developed in the
concrete operational stage.
12. An adolescent patient is very concerned about the size of their penis. Which
of the following statements is the most appropriate for the nurse to make?
A. "The growth of the penis is complete by age 13."
B. "There is little variation in the size and shape of male genitalia."
C. "Penis size can vary greatly, and many are concerned about this, but growth
continues into early adulthood."
D. "You should ask your doctor about testosterone therapy if you are concerned."
Correct Answer: C. This response validates the patient's concern, provides