A 3-month-old infant, born at 38 weeks of gestation, will hold a rattle if it is put in her hands, but she will not voluntarily grasp it. How should the nurse interpret this action?

Correct Answer: C

Rationale: At 3 months of age, most infants should be able to voluntarily grasp objects placed in their hands. This infant, who was born at 38 weeks of gestation, is showing signs of slight delay in development. Premature infants often have developmental delays, especially in motor skills, compared to full-term infants. The fact that the infant can hold a rattle if it is put in her hands is a positive sign, indicating that she is on the right track developmentally but might be a little behind schedule. Continuing to monitor the infant's progress and providing appropriate developmental stimulation can help promote further motor skill development. There is no indication at this point to suspect a significant developmental lag or a neurologic disorder like cerebral palsy without further assessment and observation.

Correct Answer: A

Rationale: At 5 months old, an infant would typically be able to roll from abdomen to back (Choice A). This is an important gross motor skill that develops during this stage. Additionally, putting their feet in their mouth when lying on their back (Choice B) is also a common movement seen at this age. Both these actions demonstrate the increasing strength and coordination of the infant's muscles as they develop and explore their physical abilities. Rolling from back to abdomen (Choice C) and sitting erect without support (Choice D) typically develop later, around 6-7 months and 8-9 months, respectively. Moving from prone to sitting position (Choice E) and adjusting posture to reach an object (Choice F) are usually mastered around 8-9 months as well.

Correct Answer: A

Rationale: The safety topic that is the priority for the nurse's accident prevention class for parents of toddlers is the appropriate use of car seat restraints. Car accidents are one of the leading causes of injuries and deaths among children, and proper car seat usage is crucial in protecting toddlers during car rides. Following the guidelines for car seat installation and usage can significantly reduce the risk of injury or death in the event of a car accident. Therefore, ensuring that parents understand and implement proper car seat restraint practices is essential in promoting the safety of toddlers. While the other safety topics are also important, the risk of injury or death in car accidents is higher compared to other accidents for toddlers, making car seat safety a priority.

Correct Answer: C

Rationale: The best nursing action in this scenario is to explain why a Band-Aid is not needed. At 5 years old, Samantha is at an age where she can begin to understand explanations. By providing her with a simple and clear explanation, the nurse can help Samantha understand that a Band-Aid is not necessary in this situation. This also promotes education and helps Samantha learn about wound healing and appropriate care. It is important to involve the child in the decision-making process and provide education to foster their understanding of their own health.

Correct Answer: C

Rationale: The nurse should be most concerned about the child's self-esteem and sense of competence. A 12-year-old male with short stature due to a constitutional growth delay may experience feelings of inadequacy or embarrassment because of his height. It is important for the nurse to address these emotional aspects of the condition and support the child in developing a positive self-image. By promoting the child's self-esteem and sense of competence, the nurse can help the child navigate any challenges associated with his height and build confidence in his abilities and worth as an individual.