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1. A nurse is assessing a 6-month-old infant who is brought
to the clinic by his mother. The nurse observes that the
infant can roll over from his back to his stomach, but not
from his stomach to his back. The nurse should:
a) Refer the infant to a developmental specialist for further
evaluation.
b) Reassure the mother that this is normal for his age.
c) Advise the mother to encourage the infant to practice
rolling over both ways.
d) *Teach the mother that rolling over from stomach to
back usually occurs later than rolling over from back to
stomach.* (Rationale: Rolling over from back to stomach is
a milestone that most infants achieve by 6 months of age,
while rolling over from stomach to back may take longer,
up to 8 months of age. Therefore, the nurse should educate
the mother about this normal variation and not worry her
unnecessarily.)
2. A nurse is caring for a 2-year-old toddler who is
hospitalized for pneumonia. The nurse notices that the
toddler often says "no" to the nurse's requests and tries to
do things by himself, such as brushing his teeth or putting
on his clothes. The nurse should:
a) *Recognize that this is a normal expression of autonomy
and allow the toddler to do simple tasks with supervision.*
(Rationale: Autonomy versus shame and doubt is the
psychosocial stage of development that toddlers go
through, according to Erikson's theory. Toddlers need to
assert their independence and develop a sense of self-
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