MCN - Final Exam
MCN - Final Exam
MCN - Final Exam
Which is not included in the diseases that are screened under the Newborn Screening
Act of the Philippines? *
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Down’s Syndrome
Phenylketonuria
Hypothyroidism
Congenital adrenal hyperplasia
3. The nurse is instructing the mother on the proper way of holding the baby, minutes
after normal spontaneous delivery. The term neonate is in the first period of reactivity.
Which of the following actions should the nurse take at this time? *
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Notify the neonatalogist of the finding.
Encourage the parents to bond with their baby.
Place the baby under the overhead warmer.
4. The nurse notes that a 6-hour-old neonate has cyanotic hands and feet. Which of
the following actions by the nurse is appropriate? *
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Apply pulse oximeter
Place child in isolette.
Swaddle baby in blanket.
Administer oxygen.
5. A mother is preparing to breastfeed her baby. Which of the following actions would
encourage the baby to open the mouth wide for feeding? *
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Holding the baby in the en face position.
Pushing down on the baby’s lower jaw.
Tickling the baby’s lips with the nipple.
7. The neonate develops jaundice 72 hours after birth. The nurse explain to the
parents that the jaundice is probably a result of : *
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A temporary bile duct obstruction commonly found in newborns
The physiologic destruction of fetal red blood cells
8. When assessing on baby's eyes, the nurse notes the following: absence of tears,
corneas of unequal size, constriction of the pupils in response to bright light, and the
presence of red circles on the pupils on ophthalmic examination. Which of these
findings need further assessment? *
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Corneas of unequal size.
9. Baby boy’s mother is preparing for breastfeeding. Which of the following hormones
influences breast milk release? *
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Follicle-stimulating hormone
Luteinizing hormone
Prolactin
Oxytocin
10. A nurse is providing discharge teaching to the parents of a newborn. Which of the
following should be included when teaching the parents how to care for the baby’s
umbilical cord? *
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Call the doctor if greenish drainage appears.
Remove it with sterile tweezers at one week of age.
Cover it with sterile dressings until it falls off.
11. A baby has just been admitted into the neonatal nursery. Before taking the
newborn’s vital signs, the nurse should warm his or her hands and the stethoscope in
order to prevent heat loss resulting from which of the following? *
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Evaporation.
Radiation.
Conduction.
Convection.
12. The neonate’s vital signs are the following: temperature = 35.8 degrees C., heart
rate = 120 bpm, and respirations = 40/minute. The infant is pink with slight
acrocyanosis. What would be the priority nursing diagnosis for the neonate? *
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Altered elimination pattern related to lack of nourishment
Potential for infection related to lack of immunity.
Altered nutrition, less than body requirements related to diminish sucking reflex.
Ineffective thermoregulation related to fluctuating environmental temperatures.
13. What is the priority nursing intervention for the nurse to prevent evaporative heat
loss in the newborn? *
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Placing the baby away from the outside wall and the windows
Keeping the baby out of drafts and away from air conditioners
Warming the stethoscope and nurse's hands before touching the baby
Drying the baby after birth and wrapping the baby in a dry blanket
14. Which nursing action is designed to avoid unnecessary heat loss by conduction in
the newborn? *
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Maintain room temperature at 70° F.
Minimizing baths
Place a blanket over the scale before weighing the infant.
15. A nurse is giving a newborn his first bath. She notes that his temperature has
decreased after the bath. What would be the best rationale of the drop in
temperature? *
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Radiation
Convection
Conduction
Evaporation
16. Which of the following best describe heat loss by convection that occurs in the
newborn? *
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By giving a bath
By wrapping in cool blanket
By placing in a drafty area of the room
17. What would be the nurse's initial action when caring for an infant with a
temperature of 36.1 *C (97.0 F) in an open crib? *
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Notify the physician immediately
Return the infant to isolette
Wrap the infant in two warmed blankets and place a cap on the head
20. The newborn is to be released from hospital at 2 days of age. The nurse performs
a physical examination before discharge and examines the neonate’s hands and
palms. Which of the following findings requires further assessment? *
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Two large creases across the palm.
Absence of creases on the palm.
Many crease across the palm.
21. What would be considered as the earliest reflexes present upon birth of the baby?
1. Sucking, rooting, Moro, swallowing 2. Gagging, Babinski, sneezing 3. Tonic neck,
grasp (palmar and plantar) 4. Stepping or walking, stretching *
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1 and 2
1,2 and 4
All except 4
22. The nurse is about to elicit the Moro reflex. Which of the following responses
should the nurse expect to see? *
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When the newborn is supine and the head is turned to one side, the arm on that same side
extends.
When the cheek of the baby is touched, the newborn turns toward the side that is touched.
When the baby is suddenly lowered or startled, the neonate’s arms straighten outward and the
knees flex.
When the lateral aspect of the sole of the baby’s foot is stroked, the toes extend and fan outward
23. Which of the following actions should the nurse take to assess for the Landau
reflex? *
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Place the infant horizontally and support him under the abdomen.
Suspend the infant in a horizontal, prone position and flex the head.
24. The nurse observes a healthy newborn lying in a supine position with the head
turned to the side, legs and arms extended on the same side and flexed on the
opposite side. What would best describe this reflex? *
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The Landau reflex
A tonic neck reflex
25. There are varied opinions as to when solid foods are supposed to be introduced to
an infant. The consensus of the majority is 4-6 months, what would be the reason for
this? 1. Salivary enzymes are not present until 2-3 months old 2. Extrusion reflex lasts
until 3-4 months 3. Swallowing reflex is not well developed 4. Digestion of solids can
take place after 3 months old *
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1,2 and 4
3 and 4
All of the above
1,2 and 3
26. While assessing the integument of a 24-hour-old newborn, the nurse notes a pink,
papular rash with vesicles superimposed on the thorax, back, and abdomen. What
would the nurse perform? *
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Move the newborn to an isolation nursery.
Take the newborn's temperature and obtain a culture of one of the vesicles
Notify the physician immediately.
Document the finding as erythema toxicum.
27. A mother noticed some bruises on her newborn girl's buttocks and she asks the
nurse who spanked her daughter. Which of the following would best describe the
marks seen by the mother? *
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Lanugo.
Mongolian spots.
Vascular nevi.
Nevus flammeus.
28. A newborn has small, whitish, pinpoint spots over the nose, which the nurse knows
are caused by retained sebaceous secretions. When charting this observation, what
would the nurse indicate this physical feature? *
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Milia
Mongolian spots
Whiteheads
Lanugo
29. A mother of a term neonate asks what the thick, white, cheesy coating is on his
skin. Which of the following best describes this finding? *
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Nevus flammeus
Lanugo
Vernix
Milia
30. To check for the presence of Epstein’s pearls, the nurse should assess which part
of the neonate’s body? *
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Mouth.
Hands.
Back.
Feet.
32. Which of the following principles would reflect with growth and development? 1.
Developmental milestones are times when certain behaviours and events occur. 2.
Progressive attainment of skills is known as developmental achievements 3. Growth
and development is a continuous process from infancy to death 4. Fine motor skills
develop before gross motor skills *
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2&3
4&1
1&2
3&4
33. Which of the following principles of growth and development most relevant to the
motor aspect that progresses from the center of the body to the extremities? *
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Proximodistal
34. Sequential trends is defined as an orderly sequence; each child normally passes
through every stage. Which of the following is NOT considered as sequential? *
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Differentiation: development from simple operations to more complex activities & functions
Positivism and Negativism stimulus enhance or defer the achievement of skill or function
Each stage is affected by preceding stage and affects those stages that follow
Critical periods: time period in which child is especially responsive to certain environmental
effects; sometimes called sensitive periods
35. About growth and development, which assessment finding indicates the child's
development proceeds from gross to refined? *
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The child's arms are the most rapidly growing part of the child's body.
The child can throw a large ball but not a small ball.
36. In what way does moral development theory differs from cognitive development
theory? *
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Cognitive development theory deals with the formation of personality.
Moral development theory predicts how a person will react in any situation.
Moral development theory characterizes the value system of people and their respect for others.
Cognitive development theory describes physical changes that take place in stages
38. Which of the following principle, states that simple skills typically develop
separately and independently but are later integrated to a more complex skills? *
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Principle of Hierarchical Integration
Proximodistal Principle
Principle of Independence of Systems
Cephalocaudal Principle
39. Which of the principle best suggests that different body systems grow at different
rates? *
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Proximodistal Principle
Cephlocaudal Principle
Principle of Independent systems
41. Personality continues to evolve over time and respond to the influences and
experiences of life, much of personality is determined by inborn traits and early
childhood experiences. What would be the best definition for theories? *
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Promises that certain things will happen in certain ways
Answer all our questions about human development
Ways of thinking that help us understand, give us questions to ask and offer looks with different
views
Can never actually be used to guide our thinking and behavior; they are just for general
knowledge
Other:
Highest stage in Kohlberg's stage of moral development, included in Level III; individuals follow
their own conscience about what is right, and behavior is the same no matter who is present
One of Kubler-Ross' five stages of grief
Maslow's third level of human needs
Erikson's stage which states that children expand their world and learn to control their new
environments, acquire feelings of competence and independence and develop leadership skills
48. Which developmental theory was based on how children learn by observing and
imitating others' behavior? *
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Classical
Operant conditioning
Psychosocial
Social learning theory
49. Which researcher believed that children adjust their understanding as they learn
about the world? *
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Skinner
Piaget
Bandura
Vygotsky
51. If parents keep a toddler dependent in areas where he is capable of using skills,
the toddler will develop a sense of which of the following? *
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Inferiority
Mistrust
Guilt
Shame
52. When teaching parents about the child’s readiness for toilet training, which of the
following signs should the nurse instruct them to watch for in the toddler? *
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Demonstrates dryness for 4 hours
Verbalizes desire to go to the bathroom
53. Which of the following toys would be most appropriate for a toddler? *
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Pull toys and blocks
Mobiles and squeeze toys
54. The mother discusses with the nurse that her toddler child asks every night for a
bedtime story. She asks why the child does this. What would the nurse explain about
this behavior? *
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Object permanence
Conservation
Dependency
Ritualism
55. The mother of a toddler asks a nurse when it is safe to place the car safety seat in
a face-forward position. What would be the best nursing response? *
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The seat should not be placed in a face-forward position unless there are safety locks in the car
When the weight of the toddler is greater than 40 lbs
The seat should never be place in a face-forward position because the risk of the child unbuckling
the harness
When the toddler weighs 20 lbs
56. Which of the following demonstrate the components of normal physical growth
and development in toddler? *
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Rides a tricycle or "big wheel", skips and hops
57. The play area in the Pediatric Unit would provide the opportunity for toddlers to
participate in, what type of play that is common for toddlers? *
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Parallel play
Team play
Associative play
Solitary play
58. What is the most common indicator of pain in toddlers? *
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Disturbed sleep
Quivering chin
Description of pain intensity
Changes in vital signs
59. A recently hospitalized 2-year-old client screams and shouts that he wants a
“bottle”. His parents are puzzled, and state that he has been drinking from a cup for
the past year. What would the nurse explain? *
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Irritability is exhibited in all age groups.
Various forms of punishment are necessary when such behaviors occur.
Regression to an earlier behavior often helps the child cope with stress and anxiety.
Temper tantrums often represent the child's need for parental attention.
60. The nurse is caring for a hospitalized toddler who was toilet trained at home. He
wets his pants. What would be the best response to this situation? *
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"It's okay; try not to wet your pants next time."
"Your mom told me you don't wet anymore; what's wrong?"
"That's okay; now let's get you cleaned up."
"I know you understand how to use the toilet; what happened?"
61. What would be the best characteristics that are normal for a 5-year-old child? *
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All of the above
Can tell full name and address
Asks searching questions about life
Knows main colors and counts to 10
62. The toddler kid is found masturbating by his mother. What would be the best
approach? *
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Redirect child's attention without punishing or verbally reprimanding but teach him that touching
genitals is not appropriate in public
Ignore the child's actuation
Pull his hands and tell him that his doing is bad
Give him a toy to play only
63. A nurse is preparing to care for a 4-year-old who has been placed in traction
following a fracture of the femur. The nurse plans care, knowing that which of the
following is the most appropriate activity for this child? *
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Large picture books
A radio
A sports vide
Crayons and coloring book
64. The mother of a 5-year-old expresses concern about her child who believes that
“Grandma is still alive” 3 months after the grandmother’s death. Which of the
following would the nurse explain the situation correctly? *
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This is a form of regression exhibited by the preschooler.
Magical thinking often accounts for a preschooler who believes that dead people will come back.
There is a need for psychological counseling for this child and family.
The child is in denial regarding Grandma's death.
65. Which of the following would a 4 year-old child attribute with unintentional injury
during hospital admission? *
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Clumsiness in playing
66. A mother of a 4-year-old expresses concern because her hospitalized child has
begun thumb sucking. The mother states that this behavior began 2 days after
hospital admission. Which response by the nurse is most appropriate? *
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"The doctor will need to be notified."
"A 4-year-old is too old for this type of behavior."
"Your child is acting like a baby."
"It is best to ignore the behavior."
67. Which of the following best describes the growth during preschool years using
motor development skills? *
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Skips & hops on one foot & rides tricycle
Good hand-finger coordination
Movements become more limber, graceful, and coordinated
Holds crayon w/ fingers
68. Which of the following would the nurse anticipate on a 4 y/o child who is
experiencing pain? 1. Views pain as a punishment 2. Verbalizes the reason for the pain
3. Blames someone else for the pain 4. Fears losing control during the painful episode
5. Will be able to explain the sequence of events leading to the pain *
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1&2
1&3
3&4
3&5
69. Based upon Eric Erickson's Theory of Psychosocial development, what is the
specific development task for a pre-school child? *
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Autonomy vs. Shame and Doubt
Trust vs. Mistrust
Industry vs. Inferiority
Initiative vs. Guilt
70. Which of these statements, when made by the nurse, is most effective when
communicating with a 4-year-old? *
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"This will be like having a little stick in your arm."
"Anything you tell me is confidential."
"Other children like having their blood pressure taken."
"Tell me where you hurt."
71. The school age child shows psychosomatic complaints due to school phobia and
refusal to go to school. Which of the following would be the right technique to be
adapted by his mother? *
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Reward school attendance
Allow the child to verbalize his feelings freely and encourage independence
Withdrawing privileges if he does not go to school
Accompany him to school and don't leave the school premises
72. A nurse is teaching the parents of a school-age child. Which teaching topic should
take priority? *
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Keeping a night light on to allay fears
Encouraging the child to dress without help
Accident prevention
73. Which of the following would be the best role of the peer group in the life of
school-age children? *
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Decreases their need to learn appropriate sex roles.
Gives them an opportunity to learn dominance and hostility.
Allows them to remain dependent on their parents for a longer time.
Provides them with security as they gain independence from their parents.
75. The nurse is preparing an 8-year-old child for a surgical procedure. What is the
most appropriate nursing intervention considering the child's stage of growth and
development? *
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Provide a written pamphlet for the child to review prior to the procedure.
Request that parents wait outside while the nurse provides instructions to the child
Provide visual aids, such as dolls, puppets, and diagrams in the explanation.
Discourage any display of emotional outbursts.
76. What would be the common response from an 8-year-old child who is about to
receive an injection for pain? *
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“ Give it to me in my other leg.”
“ I don’t need it now, I’ll take it later.”
“ I’ll be brave and not cry.”
77. Which of the following is of greatest developmental concern for a 10-year-old girl
hospitalized for the first time? *
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Fearing needles and injections
79. In discussing sexual maturation in a health class, the nurse would include the
information that secondary sex characteristics begin to appear at what age? *
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10 years in girls, 12 years in boys.
Toddler
82. When planning sex education and contraceptive teaching for adolescents, which
of the following factors should nurse consider? *
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Most teenagers use pregnancy as a way to rebel against their parents.
Most teenagers today are knowledgeable about reproduction.
Most teenagers are open about contraception but inconsistently use birth control
Neither sexual activity nor contraception requires planning.
83. According to Erik Erikson what is an appropriate intervention for a 16 year old child
that is hospitalized? *
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encourage patient to help child learn lessons missed
tell the child’s girlfriend to visit the child.
call the priest to intervene
tell the friends to visit the child
84. How can the nurse care for a hospitalized teenager best meet the adolescent's
developmental needs? *
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By explaining procedures and including the adolescent in decision making
Parenting skills
Dating skills
86. The adolescent’s inability to develop a sense of who he is and what he can
become results in a sense of which of the following? *
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Inferiority
Role diffusion
Shame
Guilt
88. Which of the following would be the most appropriate for a nurse to use when
describing menarche to a 13-year-old? *
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The entire menstrual cycle or from one “period” to another
A female’s first menstruation or menstrual“periods”
89. Which of the following best describe Erikson's stage for middle adulthood? *
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generativity versus stagnation
intimacy versus isolation
autonomy versus shame
integrity versus despair
90. Which of the following are not key features that characterize emerging
adulthood? *
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Instability
Self-focused
Identity exploration
Commitment to others
91. As a nurse, you reviewed infant safety procedures with the mother. What are the
most common types of accidents among infants? *
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Aspiration and falls
92. A nurse is assessing the following children. Which child would the nurse identify
as having the greatest risk for choking and suffocating? *
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A 4-year-old eating yogurt for lunch
A 3-year-old drinking a glass of juice
A toddler playing with his 9-year-old brother's construction set
93. As the nurse plans to teach the parents about these risks, the nurse remembers
that adolescents are at a greater risk for injury from: 1. Fall 2. Poisoning 3. Automobile
Accidents 4. Substance Abuse 5. Suffocation *
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2,3
1,2
4,5
3,4
95. In selecting appropriate toys for an infant, which would be the least factor the
nurse must consider? *
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Attractively painted with bright color
96. Which of the following would be at greatest risk for injury in the late infancy and
toddler? *
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Trying to pull up on furniture.
Growing ability to explore and oral activity
Learning to walk.
Being dropped by a caregiver.
97. Which of the following reflexes should the nurse discuss and demonstrate to
educate the parents about providing a safe environment for their newborn? *
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Tonic neck
Prone crawl
Stepping
Babinski's
98 The young mother tells the nurse that she is concerned about the safety of her 15–
month–old son, who seems to be "getting into everything" and needs to be watched
constantly. How would the nurse respond as the most important consideration in
accident prevention with toddler? *
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By not allowing them to play with dangerous items
By ensuring a safe environment by childproofing
By teaching them the meaning of "no"
By buying only age appropriate toys
99. What would the nurse advise the mother in order to refrain from preventing
suffocation of the child? *
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Closing pins when changing diapers
Propping bottles when feeding
Keeping small objects out of reach
100. When planning to teach health care topics to a group of male adolescents, which
topic should the nurse consider a priority? *
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A driver's education course is mandatory for safety