A nurse is preparing to administer an intramuscular injection to a 2-month-old infant. In which of
the following sites should the nurse plan to administer the injection?
\u2714 A. Vastus lateralis The vastus lateralis is a large, developed muscle, even in an infant. The
muscle can tolerate the volume of the injection, and there are no important nerves or blood
vessels in this muscle.
B. Dorsogluteal Receiving an injection at the dorsogluteal site at 2 months of age is
contraindicated because the muscle is poorly developed.
C. Deltoid The deltoid has a small muscle mass, and the proximity of the radial and axillary
nerves make it suitable for use only after the age of 18 months.
D. Abdomen 5 cm (2 in) from the umbilicus The abdomen is used for subcutaneous injections.
A nurse in a provider’s office enters an examination room to assess an 8-month-old infant for the
first time. Which of the following reactions by the infant should the nurse expect?
A. The infant gives the nurse a social smile. The nurse should expect social smiles to begin at 6
weeks of age; however, the nurse should not expect this from an 8-month-old infant upon
initially entering the room due to the infant’s expected fear of strangers.
\u2714 B. The infant turns away when the nurse approaches. The nurse should expect an 8-month-old
infant to have a heightened fear of strangers. The infant is expected to cling to her parent and
turn away when approached by a stranger.
C. The infant reaches out to the nurse to be held. The nurse should not expect an 8-month-old
infant to reach out as the nurse enters the room due to the infant’s expected fear of strangers.
D. The infant is responsive and alert as the nurse comes closer. Once the infant is 12 months old,
the nurse should expect an alert response to strangers once again.
A nurse is discussing play activities with a group of parents of toddlers. Which of the following
activities should the nurse recommend for this age group?
A. Jumping rope Jumping rope is a play activity that meets the gross motor ability of a
preschooler.
\u2714 B. Pushing a toy lawn mower The nurse should recommend pushing a toy lawn mower as a
play activity for a toddler. Toddlers are developmentally ready for push-pull toys, and they enjoy
play activities that allow imitation of adults.
C. Sorting colored marbles The nurse should advise parents to avoid toys that pose a risk for
aspiration by the toddler.
D. Playing a board game Playing a board game is an activity that meets the developmental ability
of a school-age child.
A nurse is assessing a 6-year-old client at a well-child visit. Which of the following findings
requires further assessment by the nurse?
\u2714 A. Presence of sparse, fine pubic hair The development of sexual characteristics prior to the
age of 9 years in boys and 8 years in girls is an indication of precocious puberty and requires
further evaluation.
B. Decreased head circumference compared to full height The head circumference of a school\u0002age child decreases when compared to full height due to skeletal lengthening.
C. Increased leg length in relation to height Body proportion varies with a slimmer appearance
and longer legs in a school-age child. Leg length increases and waist circumference decreases
related to height in this age group.
D. Presence of a loose central incisor The deciduous teeth start shedding at this age, beginning
with the lower central incisors.
A nurse is caring for a female adolescent who is being treated for frequent urinary tract infections
(UTIs). Which of the following statements by the adolescent indicates a possible cause of the
UTIs?
\u2714 A. “I have bowel movements every 4 to 5 days.” The nurse should identify that this frequency
of UTIs indicates the adolescent is constipated. Therefore, large stool masses might prevent
complete emptying of the bladder and lead to urinary stasis and infection.
B. “My mom taught me to wipe from front to back after going to the bathroom.” The adolescent
will improve perineal hygiene by wiping from front to back, which decreases the likelihood of a
UTI.
C. “I urinate every 2 to 3 hr during the day.” Emptying the bladder every 2 to 3 hours prevents
urinary stasis and infection.
D. “I don’t wear nylon underwear.” The adolescent should wear cotton underwear to help prevent
UTIs, as nylon underwear is more likely to trap bacteria in the genital area of a female client.
A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings
indicates the need for further assessment?
A. The infant is grabbing the feet and pulling them to the mouth. Infants are able to grab the feet
and pull them to their mouth at 6 months of age. At this age, the infant should also be able to
pick up a dropped object and hold a bottle.
B. The infant has a closed posterior fontanel. This is an expected finding in a 6-month-old infant.
The posterior fontanel closes at approximately 2 months of age. The anterior fontanel is closed
by 18 months of age.
\u2714 C. The infant\u2019s legs remain crossed and extended when supine. Legs that are crossed and
extended when supine is an unexpected finding and requires further assessment. At 6 months of<\/p>\n\n\n\n
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