The nurse is performing a cognitive assessment of a 2-year-old. Which behavior would alert the nurse to a developmental delay in this child?
The child does not point to named body parts.
The child cannot say name, age, and gender.
The child cannot follow a series of two independent commands.
The child has a vocabulary of 40 to 50 words.
The Correct Answer is A
A. The child does not point to named body parts. By the age of 2, most children can point to at least two body parts when asked. This ability indicates that the child understands and can process verbal instructions, which is a key cognitive milestone.
B. The child cannot say name, age, and gender. While knowing their name, age, and gender is important, it is more typical for children to achieve this milestone closer to 3 years old. Therefore, this would not necessarily indicate a developmental delay at 2 years.
C. The child cannot follow a series of two independent commands. By 2 years old, children should be able to follow simple two-step commands, such as "Pick up the toy and give it to me." This ability demonstrates their understanding and processing of sequential instructions.
D. The child has a vocabulary of 40 to 50 words. A vocabulary of 40 to 50 words is within the normal range for a 2-year-old. Most children at this age are expected to have a vocabulary of at least 50 words and start combining them into simple sentences.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The step reflex is an expected primitive reflex in infants, disappearing around 2 months of age.Therefore, if ounf in a 4 month old baby, the nurse should be concerned.
B. The plantar grasp reflex should be present in infants and typically disappears by 9 to 12 months of age.
C. Neck righting reflex is a normal response in infants, allowing them to orient their heads in relation to their body movements.
D. The Babinski reflex is typically present in infants but should disappear by around 12 months of age. If it persists beyond this age, it could indicate neurological concerns and warrant further evaluation. therefore, the reflex is normal in a 44 month old baby
Correct Answer is D
Explanation
A. Placing the baby on a soft mattress with a firm, flat pillow can increase the risk of Sudden Infant Death Syndrome (SIDS). Infants should sleep on a firm mattress without pillows or soft bedding to reduce the risk of suffocation.
B. Placing the head of the bed near the window for fresh air is not recommended due to potential drafts, temperature changes, or exposure to outdoor elements that might disturb the baby's sleep.
C. Waking a sleeping baby for feedings is generally not advised. Babies will wake on their own when hungry, and consistent nighttime feedings are essential, especially for a 3-week-old infant.
However, advice on this may vary based on the infant's individual health and weight gain, and it's best to follow the pediatrician's guidance.
D. Placing the baby on his or her back when sleeping is the recommended sleep position to reduce the risk of Sudden Infant Death Syndrome (SIDS). This practice is endorsed by pediatric healthcare professionals and is considered a critical guideline for safe infant sleep.
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