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.

Answer and Explanation

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.

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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

A. "As a nurse, I am required by law to report suspected child abuse." B. "I am unable to discuss this but can contact..." C. "The provider will be coming to explain the situation." D. "I reported the incident to my supervisor who decided to contact the authorities."

Correct Answer is A

Explanation

A. Nurses are mandated reporters, required by law to report suspected cases of child abuse or neglect to the appropriate authorities.
B. While maintaining confidentiality is important, in cases of suspected abuse, legal obligations override the need for confidentiality.
C. Involving the provider might not be immediate or necessary for explaining the situation, as the priority is reporting and ensuring the child's safety.
D. Directly reporting to authorities or involving supervisors is the responsibility of the nurse when faced with suspected child abuse.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which reflex, if found in a 4-month-old infant, would cause the nurse to be concerned?

Correct Answer is A

Explanation

A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate?

Correct Answer is A

Explanation

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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?