Question

A nurse is assessing an 18-month-old child during a well-child visit. The child's parents report that the child is not yet walking independently. The nurse should prioritize which of the following actions?

Answer 1

Correct Answers:

Conduct a thorough assessment of gross motor skills and developmental history.

Rationale :

🟠Not walking by ~18 months is a developmental red flag that warrants a comprehensive gross-motor and neuromuscular assessment.

🟠The nurse should gather a detailed prenatal, perinatal, and medical history (e.g., prematurity, hypoxia, neuromuscular conditions) to identify risk factors.

🟠Use a standardized developmental screener (e.g., ASQ, Denver) and observe tone, posture, symmetry, and gait attempts to pinpoint delay characteristics.

🟠Assess environmental and psychosocial factors (opportunities for practice, safe space, caregiver expectations) that can affect motor progression.

🟠Findings guide timely referrals (e.g., Early Intervention, PT/OT, neurology) and individualized teaching, ensuring early support during a critical window.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Using the same tool to assess the child's pain each time

Rationale :

🔷Consistency of the pain scale (e.g., FLACC, FACES) is essential for reliable trend comparison across shifts and encounters.

🔷A single, developmentally appropriate tool reduces measurement variability and improves the accuracy of treatment response evaluation.

🔷Standardized tools provide objective descriptors that enhance interprofessional communication and documentation quality.

🔷Consistent use enables timely escalation or de-escalation of analgesia based on clear, comparable data.

🔷This practice aligns with pain management guidelines emphasizing repeatable, validated measures for pediatric assessment.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

This is slow weight gain for the child's age.

Rationale :

💠Term infants typically double birth weight by ~4–6 months; an 8-lb newborn would be ~16 lb at 6 months on average.

💠A current weight of 12 lb at 6 months reflects suboptimal gain, prompting evaluation for intake, feeding technique, or illness.

💠Review feeding frequency, volume, lactation effectiveness, and formula preparation to identify modifiable contributors.

💠Assess for malabsorption, chronic disease, or psychosocial factors (e.g., food insecurity) that may impede growth.

💠Plotting on WHO growth charts helps confirm deceleration across percentiles, guiding targeted interventions and follow-up.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

This is an expected finding in this age group.

Rationale :

🟢The anterior fontanelle normally closes between 12–18 months, so open and soft at 3 months is physiologic.

🟢A soft, flat fontanelle indicates normal hydration and intracranial pressure for age.

🟢Monitoring focuses on head circumference trends and neurodevelopment, not premature closure.

🟢Concerning findings would include bulging (↑ICP) or sunken (dehydration) fontanelle, not simply being open.

🟢Provide reassurance and routine surveillance, educating caregivers on reportable changes in tension or behavior.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

This is an expected finding in this age group.

Rationale :

🟢The anterior fontanelle normally closes between 12–18 months, so open and soft at 3 months is physiologic.

🟢A soft, flat fontanelle indicates normal hydration and intracranial pressure for age.

🟢Monitoring focuses on head circumference trends and neurodevelopment, not premature closure.

🟢Concerning findings would include bulging (↑ICP) or sunken (dehydration) fontanelle, not simply being open.

🟢Provide reassurance and routine surveillance, educating caregivers on reportable changes in tension or behavior.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

The patient is 10 months old corrected age

Rationale :

🔶Corrected age = chronological age − weeks preterm; 12 months − 8 weeks (born at 32 wks) = 10 months.

🔶Use corrected age for developmental milestone assessment until around 24 months to avoid mislabeling delays.

🔶This adjustment reflects neurodevelopmental maturity rather than simply time since birth.

🔶Applying corrected age aligns expectations for skills like walking (typically 12–15 months corrected).

🔶Accurate correction supports appropriate referrals and prevents over- or under-intervention.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

The patient is 10 months old corrected age

Rationale :

🔶Corrected age = chronological age − weeks preterm; 12 months − 8 weeks (born at 32 wks) = 10 months.

🔶Use corrected age for developmental milestone assessment until around 24 months to avoid mislabeling delays.

🔶This adjustment reflects neurodevelopmental maturity rather than simply time since birth.

🔶Applying corrected age aligns expectations for skills like walking (typically 12–15 months corrected).

🔶Accurate correction supports appropriate referrals and prevents over- or under-intervention.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Advising them to use praise, not scolding

Rationale :

🚽Positive reinforcement is the cornerstone of effective toilet learning in toddlers.

🚽Praise for attempts and successes fosters autonomy and motivation, reducing resistance and anxiety.

🚽Avoiding punishment or pressure prevents toilet refusal and stool withholding patterns.

🚽Readiness signs (e.g., stays dry ≥2 hours, follows simple commands, shows awareness) should guide timing, with supportive coaching.

🚽Consistent routines, child-sized equipment, and calm language reinforce progress without shame.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

Advising them to use praise, not scolding

Rationale :

🚽Positive reinforcement is the cornerstone of effective toilet learning in toddlers.

🚽Praise for attempts and successes fosters autonomy and motivation, reducing resistance and anxiety.

🚽Avoiding punishment or pressure prevents toilet refusal and stool withholding patterns.

🚽Readiness signs (e.g., stays dry ≥2 hours, follows simple commands, shows awareness) should guide timing, with supportive coaching.

🚽Consistent routines, child-sized equipment, and calm language reinforce progress without shame.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

"We must limit Juice intake as there are unhealthy sugars found In Juice. Water is the best choice for hydration In this age group."

Rationale :

🥤Fruit juice is high in free sugars and low in fiber, contributing to excess calories and obesity risk.

🥤The AAP recommends strict limits (e.g., ≤4 oz/day for ages 1–3), with water and milk preferred for hydration/nutrition.

🥤Excess juice intake can cause dental caries, diarrhea, and appetite displacement of nutrient-dense foods.

🥤Counseling should include label reading, dilution strategies if used at all, and offering whole fruit instead.

🥤A structured plan with meal/snack timing and beverage rules supports sustainable behavior change.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

NUR 227 FALL 2025 BXA QUIZ 1

No.

1 :
A nurse is assessing an 18-month-old child during a well-child visit. The child's parents report that the child is not yet walking independently. The nurse should prioritize which of the following actions?

2 :
When the nurse is assessing a child's pain, which is most important regarding consistency in pain charting?

3 :
The RN is weighing a patient born at 8 pounds. At the 6 month visit, the patient weighs 12 pounds. The RN knows:

4 :
The RN is caring for a 3 month old infant who has an open and soft anterior fontanelle. The RN knows:

5 :
The RN is caring for a 3 month old infant who has an open and soft anterior fontanelle. The RN knows:

6 :
The RN is assessing developmental milestones in a patient. The RN knows that children should be walking around 12-15 months. What is the corrected age for a 1 year (12 month) old patient who was born at 32 weeks gestation (8 weeks early)?

7 :
The RN is assessing developmental milestones in a patient. The RN knows that children should be walking around 12-15 months. What is the corrected age for a 1 year (12 month) old patient who was born at 32 weeks gestation (8 weeks early)?

8 :
The nurse is providing anticipatory guidance to the parents of an 18-month-old girl. Which guidance will be most helpful for toilet teaching?

9 :
The nurse is providing anticipatory guidance to the parents of an 18-month-old girl. Which guidance will be most helpful for toilet teaching?

10 :
The nurse is caring for a 3-year-old toddler that is above the 95th percentile for weight. The nurse noted that the child drinks only juice. What is the best explanation for the nurse to provide when teaching the mother about healthy diet choices?

Connect With Us

NUR 227 FALL 2025 BXA QUIZ 1

No.

1 : A nurse is assessing an 18-month-old child during a well-child visit. The child's parents report that the child is not yet walking independently. The nurse should prioritize which of the following actions?

2 : When the nurse is assessing a child's pain, which is most important regarding consistency in pain charting?

3 : The RN is weighing a patient born at 8 pounds. At the 6 month visit, the patient weighs 12 pounds. The RN knows:

4 : The RN is caring for a 3 month old infant who has an open and soft anterior fontanelle. The RN knows:

5 : The RN is caring for a 3 month old infant who has an open and soft anterior fontanelle. The RN knows:

6 : The RN is assessing developmental milestones in a patient. The RN knows that children should be walking around 12-15 months. What is the corrected age for a 1 year (12 month) old patient who was born at 32 weeks gestation (8 weeks early)?

7 : The RN is assessing developmental milestones in a patient. The RN knows that children should be walking around 12-15 months. What is the corrected age for a 1 year (12 month) old patient who was born at 32 weeks gestation (8 weeks early)?

8 : The nurse is providing anticipatory guidance to the parents of an 18-month-old girl. Which guidance will be most helpful for toilet teaching?

9 : The nurse is providing anticipatory guidance to the parents of an 18-month-old girl. Which guidance will be most helpful for toilet teaching?

10 : The nurse is caring for a 3-year-old toddler that is above the 95th percentile for weight. The nurse noted that the child drinks only juice. What is the best explanation for the nurse to provide when teaching the mother about healthy diet choices?

1 :
A nurse is assessing an 18-month-old child during a well-child visit. The child's parents report that the child is not yet walking independently. The nurse should prioritize which of the following actions?

2 :
When the nurse is assessing a child's pain, which is most important regarding consistency in pain charting?

3 :
The RN is weighing a patient born at 8 pounds. At the 6 month visit, the patient weighs 12 pounds. The RN knows:

4 :
The RN is caring for a 3 month old infant who has an open and soft anterior fontanelle. The RN knows:

5 :
The RN is caring for a 3 month old infant who has an open and soft anterior fontanelle. The RN knows:

6 :
The RN is assessing developmental milestones in a patient. The RN knows that children should be walking around 12-15 months. What is the corrected age for a 1 year (12 month) old patient who was born at 32 weeks gestation (8 weeks early)?

7 :
The RN is assessing developmental milestones in a patient. The RN knows that children should be walking around 12-15 months. What is the corrected age for a 1 year (12 month) old patient who was born at 32 weeks gestation (8 weeks early)?

8 :
The nurse is providing anticipatory guidance to the parents of an 18-month-old girl. Which guidance will be most helpful for toilet teaching?

9 :
The nurse is providing anticipatory guidance to the parents of an 18-month-old girl. Which guidance will be most helpful for toilet teaching?

10 :
The nurse is caring for a 3-year-old toddler that is above the 95th percentile for weight. The nurse noted that the child drinks only juice. What is the best explanation for the nurse to provide when teaching the mother about healthy diet choices?