Essentials of Pediatric Nursing CH 3
Questions and Answers Latest Update
Origin: Chapter 3, 1
The nurse is examining a 10-month-old boy who was born 10 weeks early. Which
finding is cause for concern?
A) The child has doubled his birth weight.
B) The child exhibits plantar grasp reflex.
C) The child's head circumference is 19.5 inches.
D) No primary teeth have erupted yet. - Correct Answer an: C
Feedback:
The child's head size is large for his adjusted age (7.5 months), which would be cause
for concern. Birth weight doubles by about 4 months of age. Plantar grasp reflex does
not disappear until 9 months adjusted age. Primary teeth may not erupt until 8 months
adjusted age.
Origin: Chapter 3, 2
The nurse is teaching a new mother about the drastic growth and developmental
changes her infant will experience in the first year of life. Which statement describes a
developmental milestone occurring in infancy?
A) By 6 months of age the infant's brain weighs half that of the adult brain; at age 12
months, the brain weighs 2.5 times what it did at birth.
B) Most infants triple their birth weight by 4 to 6 months of age and quadruple their birth
weight by the time they are 1 year old.
C) The head circumference increases rapidly during the first 6 months: the average
increase is about 1 inch per month.
D) The heart triples in size over the first year of life; the average pulse rate decreases
from 120 to 140 in the newborn to about 100 in the 1-year-old. - Correct Answer an: A
Feedback:
By 6 months of age the infant's brain weighs half that of the adult brain; at age 12
months, the brain weighs 2.5 times what it did at birth. Most infants double their birth
weight by 4 to 6 months of age and triple their birth weight by the time they are 1 year
old. The head circumference increases rapidly during the first 6 months: the average
increase is about 0.6 inch (1.5 cm) per month. The heart doubles in size over the first
year of life. As the cardiovascular system matures, the average pulse rate decreases
from 120 to 140 in the newborn to about 100 in the 1-year-old.
Origin: Chapter 3, 3
The nurse is assessing the respiratory system of a newborn. Which anatomic
differences place the infant at risk for respiratory compromise? Select all that apply.
A) The nasal passages are narrower.
, B) The trachea and chest wall are less compliant.
C) The bronchi and bronchioles are shorter and wider.
D) The larynx is more funnel shaped.
E) The tongue is smaller.
F) There are significantly fewer alveoli. - Correct Answer an: A, D, F
Feedback:
In comparison with the adult, in the infant, the nasal passages are narrower, the trachea
and chest wall are more compliant, the bronchi and bronchioles are shorter and
narrower, the larynx is more funnel shaped, the tongue is larger, and there are
significantly fewer alveoli. These anatomic differences place the infant at higher risk for
respiratory compromise. The respiratory system does not reach adult levels of maturity
until about 7 years of age.
Origin: Chapter 3, 4
A new mother shows the nurse that her baby grasps her finger when she touches the
baby's palm. How might the nurse respond to this information?
A) 'This is a primitive reflex known as the plantar grasp.'
B) 'This is a primitive reflex known as the palmar grasp.'
C) 'This is a protective reflex known as rooting.'
D) 'This is a protective reflex known as the Moro reflex.' - Correct Answer an: B
Feedback:
Primitive reflexes are subcortical and involve a whole-body response. Selected primitive
reflexes present at birth include Moro, root, suck, asymmetric tonic neck, plantar and
palmar grasp, step, and Babinski. During the palmar grasp, the infant reflexively grasps
when the palm is touched. The plantar grasp occurs when the infant reflexively grasps
with the bottom of the foot when pressure is applied to the plantar surface. The root
reflex occurs when the infant's cheek is stroked and the infant turns to that side,
searching with mouth. The Moro reflex is displayed when with sudden extension of the
head, the arms abduct and move upward and the hands form a "C."
Origin: Chapter 3, 5
Which reflex, if found in a 4-month-old infant, would cause the nurse to be concerned?
A) Plantar grasp
B) Step
C) Babinski
D) Neck righting - Correct Answer an: B
Feedback:
Appropriate appearance and disappearance of primitive reflexes, along with the
development of protective reflexes, indicates a healthy neurologic system. The step
reflex is a primitive reflex that appears at birth and disappears at 4 to 8 weeks of age.
The plantar grasp reflex is a primitive reflex that appears at birth and disappears at
about the age of 9 months. The Babinski reflex is a primitive reflex that appears at birth
and disappears around the age of 12 months. The neck righting reflex is a protective
reflex that appears around the age of 4 to 6 months and persists.
Origin: Chapter 3, 6
Questions and Answers Latest Update
Origin: Chapter 3, 1
The nurse is examining a 10-month-old boy who was born 10 weeks early. Which
finding is cause for concern?
A) The child has doubled his birth weight.
B) The child exhibits plantar grasp reflex.
C) The child's head circumference is 19.5 inches.
D) No primary teeth have erupted yet. - Correct Answer an: C
Feedback:
The child's head size is large for his adjusted age (7.5 months), which would be cause
for concern. Birth weight doubles by about 4 months of age. Plantar grasp reflex does
not disappear until 9 months adjusted age. Primary teeth may not erupt until 8 months
adjusted age.
Origin: Chapter 3, 2
The nurse is teaching a new mother about the drastic growth and developmental
changes her infant will experience in the first year of life. Which statement describes a
developmental milestone occurring in infancy?
A) By 6 months of age the infant's brain weighs half that of the adult brain; at age 12
months, the brain weighs 2.5 times what it did at birth.
B) Most infants triple their birth weight by 4 to 6 months of age and quadruple their birth
weight by the time they are 1 year old.
C) The head circumference increases rapidly during the first 6 months: the average
increase is about 1 inch per month.
D) The heart triples in size over the first year of life; the average pulse rate decreases
from 120 to 140 in the newborn to about 100 in the 1-year-old. - Correct Answer an: A
Feedback:
By 6 months of age the infant's brain weighs half that of the adult brain; at age 12
months, the brain weighs 2.5 times what it did at birth. Most infants double their birth
weight by 4 to 6 months of age and triple their birth weight by the time they are 1 year
old. The head circumference increases rapidly during the first 6 months: the average
increase is about 0.6 inch (1.5 cm) per month. The heart doubles in size over the first
year of life. As the cardiovascular system matures, the average pulse rate decreases
from 120 to 140 in the newborn to about 100 in the 1-year-old.
Origin: Chapter 3, 3
The nurse is assessing the respiratory system of a newborn. Which anatomic
differences place the infant at risk for respiratory compromise? Select all that apply.
A) The nasal passages are narrower.
, B) The trachea and chest wall are less compliant.
C) The bronchi and bronchioles are shorter and wider.
D) The larynx is more funnel shaped.
E) The tongue is smaller.
F) There are significantly fewer alveoli. - Correct Answer an: A, D, F
Feedback:
In comparison with the adult, in the infant, the nasal passages are narrower, the trachea
and chest wall are more compliant, the bronchi and bronchioles are shorter and
narrower, the larynx is more funnel shaped, the tongue is larger, and there are
significantly fewer alveoli. These anatomic differences place the infant at higher risk for
respiratory compromise. The respiratory system does not reach adult levels of maturity
until about 7 years of age.
Origin: Chapter 3, 4
A new mother shows the nurse that her baby grasps her finger when she touches the
baby's palm. How might the nurse respond to this information?
A) 'This is a primitive reflex known as the plantar grasp.'
B) 'This is a primitive reflex known as the palmar grasp.'
C) 'This is a protective reflex known as rooting.'
D) 'This is a protective reflex known as the Moro reflex.' - Correct Answer an: B
Feedback:
Primitive reflexes are subcortical and involve a whole-body response. Selected primitive
reflexes present at birth include Moro, root, suck, asymmetric tonic neck, plantar and
palmar grasp, step, and Babinski. During the palmar grasp, the infant reflexively grasps
when the palm is touched. The plantar grasp occurs when the infant reflexively grasps
with the bottom of the foot when pressure is applied to the plantar surface. The root
reflex occurs when the infant's cheek is stroked and the infant turns to that side,
searching with mouth. The Moro reflex is displayed when with sudden extension of the
head, the arms abduct and move upward and the hands form a "C."
Origin: Chapter 3, 5
Which reflex, if found in a 4-month-old infant, would cause the nurse to be concerned?
A) Plantar grasp
B) Step
C) Babinski
D) Neck righting - Correct Answer an: B
Feedback:
Appropriate appearance and disappearance of primitive reflexes, along with the
development of protective reflexes, indicates a healthy neurologic system. The step
reflex is a primitive reflex that appears at birth and disappears at 4 to 8 weeks of age.
The plantar grasp reflex is a primitive reflex that appears at birth and disappears at
about the age of 9 months. The Babinski reflex is a primitive reflex that appears at birth
and disappears around the age of 12 months. The neck righting reflex is a protective
reflex that appears around the age of 4 to 6 months and persists.
Origin: Chapter 3, 6
