Essentials of Pediatric Nursing CH 3
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. - ANS Ans: 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 birthweight by 4 to 6 months of age and quadruple their birthweight 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. - ANS Ans: 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 birthweight by 4 to 6 months
of age and triple their birthweight 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. - ANS Ans: 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.' - ANS Ans: 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 - ANS Ans: 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
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. - ANS Ans: 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 birthweight by 4 to 6 months of age and quadruple their birthweight 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. - ANS Ans: 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 birthweight by 4 to 6 months
of age and triple their birthweight 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. - ANS Ans: 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.' - ANS Ans: 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 - ANS Ans: 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
