McKinney Maternal Test Bank for nclex Study Guide Questions with Answer
2. An immunocompromised child is in the clinic for immunizations. Which vaccine
prescriptions should the nurse question? (Select all that apply.)
a. DTaP
b. HepA
c. IPV
d. Varicella
e. MMR - correct answersD, E
Children who are immunologically compromised should not receive live viral vaccines.
Varicella is a live vaccine and should not be given except in special circumstances. MMR is a
live vaccine and should not be given to immunologically compromised children. DTaP,
HepA, and IPV can be given safely.
PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 77 OBJ: Nursing Process: Planning
MSC: Client Needs: Physiologic Integrity
3. A preschool aged child is in the clinic for a well-child checkup. Which statement identifies an
appropriate level of language development in this child? (Select all that apply.)
a. Vocabulary of 300 words
b. Relates elaborate tales
c. Uses correct grammar in sentences
d. Able to pronounce consonants clearly
e. Expresses abstract thought - correct answersB, C
The 4-year-old child is able to use correct grammar in sentence structure and can tell elaborate
tales and stories. A vocabulary of 300 words is appropriate for a 2-year-old. The 4-year-old
child typically has difficulty in pronouncing consonants. The use of language to express
abstract thought is developmentally appropriate for the adolescent. PTS: 1 DIF: Cognitive Level:
Knowledge/Remembering
REF: p. 62 OBJ: Nursing Process: Assessment
,MSC: Client Needs: Health Promotion and Maintenance
4. A 2-month-old child has not had any immunizations. Which ones should the nurse prepare to
give? (Select all that apply.)
a. Hib
b. HepB
c. MCV
d. Varicella
e. HPV - correct answersA, B, C, D
Hib, HepB, MCV, and varicella are all appropriate vaccinations for this child. HPV is for
adolescents. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 75 OBJ: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
Chapter 06: Health Promotion for the Infant
McKinney: Evolve Resources for Maternal-Child Nursing, 5th Edition MULTIPLE CHOICE
1. A nurse assessing a 2-month-old infant notes that the child can briefly hold the head erect
when held against the shoulder. What action by the nurse is best?
a. Document the findings in the child's chart.
b. Notify the provider immediately.
c. Conduct a lead-exposure assessment.
d. Prepare the parents for genetic testing. - correct answersA
A 2-month-old infant is able to briefly hold the head erect. If a parent were holding the infant
against the parent's shoulder, the infant would be able to lift his or her head briefly. Since this
is normal behavior, all that is required of the nurse is documentation. There is no need to
notify the provider immediately, conduct a lead-exposure assessment, or prepare the parents
for genetic testing. PTS: 1 DIF: Cognitive Level: Application/Applying
REF: Table 6.1 OBJ: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
,2. Approximately how much would a newborn who weighed 7 pounds 6 ounces at birth weigh at
1 year of age?
a. 14 3/4 lb
b. 22 1/8 lb
c. 29 1/2 lb
d. Unable to estimate weigh at 1 year - correct answersB
An infant triples birth weight by 1 year of age. The other calculations are incorrect. PTS: 1 DIF: Cognitive
Level: Application/Applying
REF: p. 83 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
3. Which statement made by a mother is consistent with a developmental delay?
a. "I notice my 9-month-old infant responds consistently to his name."
b. "My 12-month-old child does not get herself to a sitting position or pull to stand."
c. "I am so happy when my 1 1/2-month-old infant smiles at me."
d. "My 5-month-old infant is not rolling over in both directions yet." - correct answersB
Critical developmental milestones for gross motor development in a 12-month-old include
standing briefly without support, getting to a sitting position, and pulling to stand. If a
12-month-old child does not perform these activities, it may be indicative of a developmental
delay. An infant who responds to his name at 9 months of age is demonstrating abilities to
both hear and interpret sound. A social smile is present by 2 months of age. Rolling over in
both directions is not a critical milestone for gross motor development until the child reaches
6 months of age. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding
REF: Table 6.1 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
4. The nurse is performing a routine assessment on a 14-month-old infant and notes that the
anterior fontanel is closed. This should be interpreted as a(n)
, a. normal finding—nurse should document finding in chart.
b. questionable finding—infant should be rechecked in 1 month.
c. abnormal finding—indicates need for immediate referral to practitioner.
d. abnormal finding—indicates need for developmental assessment. - correct answersA
This is a normal finding. The anterior fontanel closes between ages 12 and 18 months. The
posterior fontanel closes between 2 and 3 months of age. There is no need for a recheck, a
referral, or a developmental assessment. PTS: 1 DIF: Cognitive Level: Analysis/Analyzing
REF: p. 93 | Table 6.1 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
5. The nurse advises the mother of a 3-month-old exclusively breastfed infant to
a. start giving the infant a vitamin D supplement.
b. start using an infant feeder and add rice cereal to the formula.
c. start feeding the infant rice cereal with a spoon at the evening feeding.
d. continue breastfeeding without any supplements. - correct answersA
Breast milk does not provide an adequate amount of dietary vitamin D. Infants who are
exclusively breastfed need vitamin D supplements to prevent rickets. An infant feeder is an
inappropriate method of providing the infant with caloric intake. Solid foods are not
recommended for a 3-month-old infant. Rice cereal and other solid foods are contraindicated
in a 3-month-old infant. Solid feedings do not typically begin before 4 to 6 months of age. PTS: 1 DIF:
Cognitive Level: Comprehension/Understanding
REF: p. 93 | Table 6.1 OBJ: Integrated Process: Teaching-Learning
MSC: Client Needs: Health Promotion and Maintenance
6. At what age is an infant first expected to locate an object hidden from view?
a. 4 months of age
b. 6 months of age
c. 9 months of age
d. 20 months of age - correct answersC
2. An immunocompromised child is in the clinic for immunizations. Which vaccine
prescriptions should the nurse question? (Select all that apply.)
a. DTaP
b. HepA
c. IPV
d. Varicella
e. MMR - correct answersD, E
Children who are immunologically compromised should not receive live viral vaccines.
Varicella is a live vaccine and should not be given except in special circumstances. MMR is a
live vaccine and should not be given to immunologically compromised children. DTaP,
HepA, and IPV can be given safely.
PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 77 OBJ: Nursing Process: Planning
MSC: Client Needs: Physiologic Integrity
3. A preschool aged child is in the clinic for a well-child checkup. Which statement identifies an
appropriate level of language development in this child? (Select all that apply.)
a. Vocabulary of 300 words
b. Relates elaborate tales
c. Uses correct grammar in sentences
d. Able to pronounce consonants clearly
e. Expresses abstract thought - correct answersB, C
The 4-year-old child is able to use correct grammar in sentence structure and can tell elaborate
tales and stories. A vocabulary of 300 words is appropriate for a 2-year-old. The 4-year-old
child typically has difficulty in pronouncing consonants. The use of language to express
abstract thought is developmentally appropriate for the adolescent. PTS: 1 DIF: Cognitive Level:
Knowledge/Remembering
REF: p. 62 OBJ: Nursing Process: Assessment
,MSC: Client Needs: Health Promotion and Maintenance
4. A 2-month-old child has not had any immunizations. Which ones should the nurse prepare to
give? (Select all that apply.)
a. Hib
b. HepB
c. MCV
d. Varicella
e. HPV - correct answersA, B, C, D
Hib, HepB, MCV, and varicella are all appropriate vaccinations for this child. HPV is for
adolescents. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 75 OBJ: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
Chapter 06: Health Promotion for the Infant
McKinney: Evolve Resources for Maternal-Child Nursing, 5th Edition MULTIPLE CHOICE
1. A nurse assessing a 2-month-old infant notes that the child can briefly hold the head erect
when held against the shoulder. What action by the nurse is best?
a. Document the findings in the child's chart.
b. Notify the provider immediately.
c. Conduct a lead-exposure assessment.
d. Prepare the parents for genetic testing. - correct answersA
A 2-month-old infant is able to briefly hold the head erect. If a parent were holding the infant
against the parent's shoulder, the infant would be able to lift his or her head briefly. Since this
is normal behavior, all that is required of the nurse is documentation. There is no need to
notify the provider immediately, conduct a lead-exposure assessment, or prepare the parents
for genetic testing. PTS: 1 DIF: Cognitive Level: Application/Applying
REF: Table 6.1 OBJ: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
,2. Approximately how much would a newborn who weighed 7 pounds 6 ounces at birth weigh at
1 year of age?
a. 14 3/4 lb
b. 22 1/8 lb
c. 29 1/2 lb
d. Unable to estimate weigh at 1 year - correct answersB
An infant triples birth weight by 1 year of age. The other calculations are incorrect. PTS: 1 DIF: Cognitive
Level: Application/Applying
REF: p. 83 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
3. Which statement made by a mother is consistent with a developmental delay?
a. "I notice my 9-month-old infant responds consistently to his name."
b. "My 12-month-old child does not get herself to a sitting position or pull to stand."
c. "I am so happy when my 1 1/2-month-old infant smiles at me."
d. "My 5-month-old infant is not rolling over in both directions yet." - correct answersB
Critical developmental milestones for gross motor development in a 12-month-old include
standing briefly without support, getting to a sitting position, and pulling to stand. If a
12-month-old child does not perform these activities, it may be indicative of a developmental
delay. An infant who responds to his name at 9 months of age is demonstrating abilities to
both hear and interpret sound. A social smile is present by 2 months of age. Rolling over in
both directions is not a critical milestone for gross motor development until the child reaches
6 months of age. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding
REF: Table 6.1 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
4. The nurse is performing a routine assessment on a 14-month-old infant and notes that the
anterior fontanel is closed. This should be interpreted as a(n)
, a. normal finding—nurse should document finding in chart.
b. questionable finding—infant should be rechecked in 1 month.
c. abnormal finding—indicates need for immediate referral to practitioner.
d. abnormal finding—indicates need for developmental assessment. - correct answersA
This is a normal finding. The anterior fontanel closes between ages 12 and 18 months. The
posterior fontanel closes between 2 and 3 months of age. There is no need for a recheck, a
referral, or a developmental assessment. PTS: 1 DIF: Cognitive Level: Analysis/Analyzing
REF: p. 93 | Table 6.1 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
5. The nurse advises the mother of a 3-month-old exclusively breastfed infant to
a. start giving the infant a vitamin D supplement.
b. start using an infant feeder and add rice cereal to the formula.
c. start feeding the infant rice cereal with a spoon at the evening feeding.
d. continue breastfeeding without any supplements. - correct answersA
Breast milk does not provide an adequate amount of dietary vitamin D. Infants who are
exclusively breastfed need vitamin D supplements to prevent rickets. An infant feeder is an
inappropriate method of providing the infant with caloric intake. Solid foods are not
recommended for a 3-month-old infant. Rice cereal and other solid foods are contraindicated
in a 3-month-old infant. Solid feedings do not typically begin before 4 to 6 months of age. PTS: 1 DIF:
Cognitive Level: Comprehension/Understanding
REF: p. 93 | Table 6.1 OBJ: Integrated Process: Teaching-Learning
MSC: Client Needs: Health Promotion and Maintenance
6. At what age is an infant first expected to locate an object hidden from view?
a. 4 months of age
b. 6 months of age
c. 9 months of age
d. 20 months of age - correct answersC
