Chapter 13 Notes

In uences on Growth and Development

● Nature versus nurture
● Nature: traits inherent in the infant at birth
● Nurture: in uence of external events
● Parenting received
● Culture
● Times in which a child lives
● Various theories, stages, principles, and models
INFLUENCES ON GROWTH AND DEVELOPMENT
The debate over nature versus nurture is longstanding. Which is the more powerful in uence in
forming a person’s essence? Nature describes the traits inherent in the infant at birth: biologically
imposed idiosyncratic factors that create what and how each person “is.” Nurture, on the other
hand, refers to the in uence of external events such as parenting received, culture, or the times in
which a child lives. It appears that both are intrinsically in uential. Overall, genes are
responsible for the basic wiring plan—for forming all of the cells (neurons) and general
connections between different brain regions—while experience is responsible for ne-tuning
those connections, helping each child adapt to the particular environment to which they belong.
Child development has been described with various theories, stages, principles, and models. In
each of these frame-works, child development is typically an organized sequence of advancing
milestones. Nursing care promoting normal growth and development must be individualized to
each child and incorporated into the nursing plan of care; therefore, the nurse must assess the
developmental age and stage of the child to anticipate normal growth and development
expectations.
While each child grows and gains skills at their own pace, overall, children move through
milestones in a predictable manner. These concepts of growth and development happen in an
expected and sequential pattern. The role of the nurse is to monitor the major growth and
developmental milestones in the areas of physical growth and cognitive, emotional, social, and
motor development. If a child is missing milestones, or has regressed or lost milestones, these are
red ags for further evaluation and possible referral to a specialist. This chapter will review the
important concepts of growth and development. This should include measurement of height,
weight, head circumference, and body mass index. By plotting measurements on a standardized
growth chart, the nurse can track and identify alterations in normal growth and development.
In addition to measuring and plotting growth parameters to assess physical growth, the nurse
should also assess for achieved developmental milestones and identify any red ags or speci c
needs of each child based on their stage of development. The nurse can assist the family to
understand developmental needs of the child and provide direction if there are any concerns for
developmental delays or de cits.
In addition, the nurse should also understand that growth and development is an individualized
and unique process for each child and that variability in ages of achievement of milestones may
exist from child to child. The nurse should provide appropriate education including anticipatory
guidance to the parents about the normal trajectory of growth and development. Once the nurse
and family members have identi ed developmental goals for the child, age-appropriate toys,

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 stimulation, play, nutrition, and sleep should be provided to facilitate normal growth and
development.

● Guiding PriFamily partnership and collaboration

● Sibling involvement Growth: Can grow physically, mentally,
psychosocially, and cognitively.
● Information sharing
● Participation and visitation
● Cultural implications
● Principles of Family Centered Care

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Principles of Childhood Growth and Development

Growth: continuous adjustment in the size of the child, internally and externally
Development: ongoing process of adapting throughout the life span
Continuous process from conception to death
Cephalocaudal
Proximodistally
PRINCIPLES OF CHILDHOOD GROWTH AND DEVELOPMENT
It is inherently pleasurable to watch a baby grow and develop. Each child does so at their own
pace. One child may move quickly through physical tasks, only to be slower with words. Another
child may be emotionally tuned into the needs of others while peers are still very self-focused.
Despite these differences, development occurs in an orderly sequence, and each child should
progress through the predictable stages within a certain time frame.
Growth refers to the continuous adjustment in the size of the child, internally and externally.
Development refers to the ongoing process of adapting throughout the life span. Growth and
development is a continuous process from conception to death. For the child, growth “spurts”
tend to be followed by periods of relative “rest” because it takes plenty of energy to continue the
growth process. The periods of rest allow the child to incorporate the new growth or the newly
developed skill into their personal repertoire more completely before attempting the next level.
Three primary considerations are related to growth and development. First, development
proceeds in a cephalocaudal direction. Cephalocaudal is a progression from head to toe—top to
bottom. For example, the baby’s brain develops quickly; therefore, the head grows rst in
comparison to the rest of the body. The child gains head and neck control before learning to
grasp or sit up. Second, development proceeds proximodistally. This means children develop
from near to far and midline to periphery. For example, the torso develops before the arms and
legs, and development proceeds to the hands and feet and then to the ngers and toes. The third
consideration is that development proceeds from gross motor skills to ne motor skills, or
differentiation. Gross motor skills such as running, jumping, or riding a bike provide the
foundation for ne motor developments such as eating, coloring, or buttoning a shirt (Box 13-1).

Erik Erickson
Psychosocial development theories
Psychosocial Development Theories
The psychosocial domain refers to the psychological and emotional progression of the child and
the relationships with others who are involved in the child’s life. Although there are many

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 Time Always Involves Incredible Ideas (Trust, Autonomy, Initiative, Industry, and Identity)

psychosocial theorists, this chapter describes the well-known theories of Sigmund Freud and
Erik Erikson.
Identi ed seven stages of development
Erik Erikson
Erik Erikson (1902–1994) was a contemporary of Freud. Unlike Freud, who attributed
personality formation only to the interplay within a person’s family of origin, Erikson focused on
the in uence of social interaction. Erikson identi ed seven stages of development. Mastery of
each stage requires that the individual achieve a balance between two tasks (con icting
variables). Each stage represents a crisis that must be resolved to move on to the next stage in a
healthy manner. Erikson’s stages (listed and explained in the following sections) are well known
and are used often in tracking the development of children.
Trust vs. mistrust: birth–1 year
In the first year I must trust, or I will fuss
TRUST VS. MISTRUST
This stage, which occurs between birth and 1 year, requires infants to develop trust when the
parental gure cares for them and meets needs such as diaper changing and feeding. The infant
develops a sense of mistrust if basic needs are not met; for example, they may be left in the crib,
wear a dirty diaper, or go hungry. Through trust, the infant gains con dence in personal worth
and well-being along with connectedness to others. Failure to master this stage leaves a sense of
hopelessness and disconnectedness. Examples of this disconnect can be seen in infants with
failure to thrive or attachment disorders. Even adults who have problems maintaining signi cant
relationships may be unable to trust others.
Autonomy vs. shame and doubt: 1–3 years At 2 I can do
AUTONOMY VS. SHAME AND DOUBT
This stage occurs between 1 and 3 years of age as the child learns to balance independence and
self-suf ciency against the predictable sense of uncertainty and misgiving when placed in life’s
situations. It is the time for the child to establish willpower, determination, and a can-do attitude.
An example of this stage happens when the toddler wants to choose clothing and dress
independently. The struggle happens when the parents allow the child to make personal choices
yet expect the choices to be socially acceptable. At this age, the child can do many new things
and wants to explore everything. This newfound independence is accompanied by new rules that
may cause internal con ict. The child must develop personal abilities while struggling with both
fears and wishes. The child has self-doubt later in life if this stage is not successfully met.
Initiative vs. guilt: 3–6 years
A 3-6 I have a bag of tricks
INITIATIVE VS. GUILT
Initiative versus guilt occurs between 3 and 6 years of age. The child’s task during this stage is to
develop the resourcefulness to achieve and learn new things without receiving self-reproach. It is
dif cult for a young child to resolve the con ict between wanting to be independent and needing
to stay attached to parents. The child’s learning of new songs, games, or jokes are good examples
of initiative. The child feels con dent to try new ideas. It is important that parents and teachers
encourage this initiative to help the child develop a sense of purpose. If initiative is discouraged
or ignored, the child may feel guilt and lack of resourcefulness.
Industry vs. inferiority: 6–12 years At 6-12 work hard or feel unwell
INDUSTRY VS. INFERIORITY
Industry versus inferiority occurs between the ages of 6 and 12. In this stage, the child develops a
sense of con dence through mastery of tasks. This sense of accomplishment can be
counterbalanced by a sense of inadequacy or inferiority that comes from failing. The realization

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 that the child is competent is one of the important building blocks in the development of self-
esteem. Industry is evident when the child can do homework independently and regulate social
behavior. Performing the prescribed tasks at school or home also shows industry. If the child
cannot accomplish realistic expected tasks, the feeling of inferiority may result.
Identity vs. role confusion: 12–18 years
At 12-18 I am finding my scene
IDENTITY VS. ROLE CONFUSION
Identity versus role confusion occurs between the ages of 12 and 18. This is a time of forging
ahead and acquiring a clear sense of self as an individual in the face of new and at times
con icting demands or desires. During this stage, the adolescent wants to de ne “what to be
when I grow up.” The adolescent concentrates on goals and life plans separate from those of
peers and family. At this point, the adolescent child can think about self as well as others and
proceeds accordingly. An adolescent who is unable to make decisions about possible career
choices, a personal belief and value system, and sexual orientation, for example, may develop a
weak sense of self and be incapable of committing to an identity. This indecision leads to role
confusion.

Jean Piaget
Sensorimotor stage: Birth to age 2 years
Preoperational stage: 2-7 years
Concrete operational stage: 7-11 years
Formal operational stage: 11-15 years
Cognitive Theories
Cognitive theory focuses on how an individual thinks and how thinking in uences worldview.
The capacity to think develops over time and with experience. Jean Piaget (1896– 1980), a Swiss
psychologist, studied the development of cognition in children. In Piaget and Inhelder’s book,
The Psychology of the Child (1969), information was presented about how children think and
learn. Thinking and learning for children take place through four distinct stages. The initial
period, the sensorimotor stage, takes place from birth to age 2. During this time, the primary
means of cognition is through the senses. The child takes in and processes information strictly on
a physiological or emotional level.
At the age of 2, the child begins to use cognitive processes to respond to the world physically.
The preoperational stage (ages 2–7 years) considers the development of motor skills and is
divided into two substages: preconceptual and intuitive. The child is still not capable of logical
thinking, but because of an increased ability to use words and actions together, the child is
increasingly able to connect cognitively with the world.
The third stage is the concrete operational stage. At this stage, the 7- to 11-year-old child can
organize thoughts in a logical order. The child can categorize and label objects. It is also possible
at this stage for the child to solve concrete problems.
Piaget’s nal stage of cognitive development is the formal operational stage during which the 11-
to 15-year-old child uses abstract reasoning to handle dif cult concepts and can analyze both
sides of an issue.

Small (0-2)
Preschooler (2-7)
Children (7-11)
Fly (12+)

Sensorimotor, Preoperational, Concrete, Formal 4

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 Newborn Re exes and Neurological Development

● Rooting
● Sucking
● Moro
● Grasping
● Babinski

Re exes and Neurological Development

Primitive re exes are the adaptive and innate mechanisms that protect the developing infant
while the brain is maturing. This is the rst sign of an intact neurological system. However,
failure of these re exes to disappear can signify altered or delayed neurological development.
The re exes are controlled by the lower brain centers. Several re exes present at birth or shortly
after help determine normal or altered neurological development. The re exes present at birth
naturally disappear by 9 months.
As the nurse performs an assessment, it is imperative to note important infant re exes:
• Rooting: Infant’s head turns and they begin to suck when the cheek or lower lip is
stroked.
• Sucking: Sucking motion of lips, mouth, and tongue allows the infant to take in
sustenance.
• Moro: Startle response with sudden jarring causes extension of the head. The
arms abduct and move upward. The hands form a “C.”
• Grasping: This is noted when the palms of the hands or soles of the feet are
stroked, causing ngers or toes to curl inward.
• Babinski: This is the turning in of the foot and fanning out of the toes when the
sole of the foot is stroked.
At birth, the lower portions of the nervous system, the spinal cord, and the brainstem are already
developed. These structures are necessary for the infant to sustain basic body functions and
primitive re exes. As the infant matures, the higher sections of the nervous system become more
developed. For example, the limbic system and the cerebral cortex are responsible for ongoing
learning that occurs during the life span.

Newborn and Infant

● Sensory development
Sensory Development
Touch is an extremely important sense and is the rst sense to develop (Fig. 13-1). The ability to
feel objects, textures, and other people opens the newborn’s world of learning. It is important for
the infant to experience soft, comforting textures. The ability to experience pain is also an
extremely important element, particularly as a protective device. If the infant experiences pain,
they react to pain with the whole body by quickly extending and then retracting the extremities.
Along with this reaction, the infant cries.
Smell and taste begin developing in utero and are intrinsically connected. Infants respond to
smells within the rst few days and have an innate preference for sweet tastes. The nurse is
aware that infants can recognize their mother’s smell long before they achieve visual recognition.
Hearing is well developed at birth. A newborn can immediately recognize the difference between
male and female voices and will generally turn toward the female voice. By the second week, the
newborn can recognize the sound of the mother’s voice. A newborn’s ability to discriminate

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 sounds develops quickly, contributing to language development. By the time the infant is 3
months old, the infant jabbers and begins to imitate sounds. During the next few months, the
infant becomes more adept at responding to and imitating familiar sounds by smiling and cooing.
Vision is the least developed of the senses at birth. Newborns are fascinated with faces and with
designs or objects that resemble faces. A newborn is able to remember an object but only in the
exact form originally seen (e.g., if the child sees a sister in pigtails, the child does not recognize
the sister with her hair down). Infants are most attracted to bright colors and to black and white
because of the limited nature of their vision. The newborn generally has poor peripheral vision
until 10 weeks of age. Within the rst 3 months, the infant will watch faces intently, follow
moving objects, and recognize familiar objects and people at a distance. There will also be the
beginnings of eye–hand coordination. Binocular vision (ability to use both eyes to see) develops
at about 4 or 5 months of age. The capacity to distinguish colors and to see things in the distance
develops throughout the rst 7 to 12 months.
● Physical development
Physical Development
Growth is rapid. Infants gain 1.5 pounds (680 g)/month, double their weight by 6 months, and
triple it by 1 year. Height increases by 1 inch (2.5 cm)/month for the rst 6 months and slows
during the second 6 months. A newborn’s head is proportionally larger than the rest of the body,
which is in keeping with the cephalocaudal course of development. The newborn’s head grows
rapidly during the rst month as the brain grows. By the time the infant reaches 1 year of age, the
head and chest circumferences are about the same.
For the infant to move or to perform actions (motor skills), the infant must have adequate muscle
development. At birth, the newborn’s movement is involuntary. It takes the infant time to mature
physically to be able to demonstrate motor skills. Gross motor skills (the ability to use large
muscles for movement) are the rst to develop in the newborn and infant. Generally, by the end
of the rst 3 months of life, the infant can raise the head and chest while lying on the belly,
stretch the legs out and kick from a prone position, and roll from side to side (Fig. 13-2). The
infant can turn over completely at about 6 or 7 months of age. By 8 to 9 months of age, the infant
begins to crawl and then, by using high objects, the infant can begin pulling up. Once the infant
has mastered an upright position, they may begin to cruise (walking while holding on to
furniture) or even attempt to walk unaided. It is important to remember that every child develops
at their own pace. One child may be walking before their rst birthday, while another does not
walk until months later.
Fine motor skills (the use of muscles to accomplish minute tasks like pinching or picking up
food) build upon the gross motor skills (Fig. 13-3). Those ne motor skills that develop between
6 and 12 months include the ability to stack large objects, scribble, bang on pots and pans, and
transfer objects from one hand to another and back again.
● Cognitive development
Cognitive Development
Infancy corresponds to Piaget’s sensorimotor stage of development. The infant uses the ve
senses to explore and to learn about the world. For example, the infant learns that lip smacking
when hungry leads to a full stomach. When the infant’s belly is full, physical needs are met, and
they can begin to explore the environment. Ultimately, the infant learns that they can have an
effect within that environment. The infant must achieve three major tasks during this phase of
development:

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 I Separation. The infant recognizes that there is no merging with or attachment to

familiar people (family members).
I Object Permanence. The infant knows that an object or person still exists even if
covered up or removed from sight; this is why infants respond so strongly to peek-a-boo.
I Mental Representation. The infant has the ability to use symbols to communicate.
Piaget also identi ed six substages within the sensorimotor stage that describe mental
representation. It is important to note that four of these substages occur during the rst year of
life. The rst substage, use of re exes, is present at birth. The majority of the re exes are
necessary for survival and disappear during the rst 9 months. The second substage, primary
circular reactions (1–4 months), takes place when the infant responds to things that give pleasure.
The infant’s response encourages caregivers to continue providing pleasurable experiences. The
third substage, secondary circular reactions, begins when the infant recognizes cause and effect.
For example, the actions that the infant can perform independently begin to capture their
attention (e.g., shaking a rattle). The fourth substage begins around 8 to 12 months when the
infant becomes deliberate with their actions. During substage 4, coordination of secondary
schemes, the infant intentionally seeks out objects. The infant now knows that pushing a button
starts the music on a toy. During this substage, the infant also develops object permanence. The
remaining substages, tertiary circular reactions (making interesting things last such as hitting a
drum with a stick and making the rat-a-tat-tat sound) and mental combinations (problem-solving
such as putting a toy down to open a drawer), take place during the toddler stage of development.
● Language development
Language Development
Infants initially communicate through the universal language of crying to indicate physical
discomfort or loneliness. As a mother or father responds to the cries, the infant learns to
communicate more deliberately. The nurse must recognize that an infant’s early speech is
characterized by crying, babbling, and imitation. In uences on language development include
maturation of the brain and the degree and quality of social interaction. If families respond
favorably to the infant’s sounds, like “ba” for bottle or “da” for daddy, the infant is more likely to
repeat these sounds, thus bringing the infant closer to the native language.
● Psychosocial development
Psychosocial Development
In infants, the rst displays of emotions, crying and smiling, are related to physiological needs
rather than to psychological stimuli. For example, the newborn wails loudly when physically
uncomfortable and smiles involuntarily during sleep. However, by the time the baby is 2 weeks
of age, the smiles begin to signify contentment and elicit a positive family response. The infant’s
smile then becomes social, and interaction with the environment occurs.
Corresponding with Erikson’s psychosocial stage of trust versus mistrust, the nurse recognizes
that this is a critical time for the newborn to absorb the whole environment along with its related
experiences. The caretaker’s task is to respond to the infant in such ways as to engender a sense
of security and well-being. Essentially, the infant’s mission is to develop a sense that their
caretakers are reliable and present.
Ainsworth described four stages of attachment. During the rst stage (birth to 2 months), the
newborn and infant randomly respond to anyone. By the second stage (8–12 weeks), the infant
begins to respond more to the mother than to anyone else, but the infant continues to respond
indiscriminately to others. It is not until the third stage (6 or 7 months) that the infant
demonstrates a strong connection to the mother and possibly develops a fear of strangers. Not all

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 infants develop stranger anxiety. Throughout the rst year, the infant develops attachments to all
the important people in the family. Achieving the necessary milestones is essential for the infant
to move on to the next stage of psychosocial development. An example of psychosocial
development is the infant becoming more aware of others by responding with a social smile and
tracking their parents’ or others’ faces (Fig. 13-4).
● Discipline
Discipline
Discipline plays an important role in the psychosocial development of the infant because it helps
correct misbehavior and mold moral character. Infants learn about safe boundaries and trusting
relationships through effective discipline.
The nurse helps parents determine how they plan to discipline their child now and later as the
child grows and develops. The American Academy of Pediatrics indicates that early forms of
discipline take place when the caregiver molds and structures the infant’s daily routines and
responds to the infant’s needs. Limit-setting acclimates the infant to the world and keeps them
out of harm’s way. It is important to note that parents often learn how to discipline from their
own experiences as children. It is essential that parents be taught appropriate strategies for
teaching and limit-setting.
● Anticipatory guidance
Anticipatory Guidance
Infancy is a period of tremendous growth and development. As infants acquire new skills at a
rapid rate, parents must know what to expect at each stage. In the rst year, infants see a health-
care provider at regular intervals for physical assessment and immunizations. Nurses are in a
unique position to provide anticipatory guidance during each of these visits. It is important to
provide teaching regarding nutrition, health promotion, safety, sleep-wake patterns, growth and
development, and discipline (Box 13-4). Health promotion and safety are priority topics to
approach with parents. They need to know the signs and symptoms of illness, when to call the
health-care provider, and procedures to follow in an emergency. Infants require a safe
environment, from cribs and car seats to a childproofed home.

Toddler (1–3 Years)

● Physical development
Physical Development
By the time the infant reaches 1 year of age, physical growth has slowed. For each year between
the ages of 1 and 3, the typical toddler gains 3 to 5 pounds (1.3–2.6 kg) and grows 3 inches (7.6
cm) taller. Most of the toddler’s energy during this period is directed to other realms of
development. As the physical growth rate slows, the toddler develops physical, cognitive, and
emotional skills that help them become more independent. As the toddler develops mobility, they
explore how things work and senses become more re ned.
The toddler uses newly acquired gross motor skills to run, jump, and move up and down stairs
with increasing ease. Around age 3, the toddler may learn to ride a tricycle or slide down the
slide in the park without help. This newfound freedom and movement create many opportunities
for danger as the toddler moves quickly from one new experience to another.
Fine motor skills continue to develop rapidly in this age group. The toddler can hold a spoon or a
large crayon appropriately and continues to make artwork that is more representative of the
object they are trying to depict. The toddler is increasingly able to manipulate smaller toys (Table
13-6).

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 ● Cognitive development
Cognitive Development
Early toddlerhood corresponds with Piaget’s fth substage of cognitive development, tertiary
circular reactions, during which time the toddler experiments and learns new behaviors. The
toddler then transitions into Piaget’s sixth substage, mental combinations, when they begin to
understand cause and effect and are able to imitate others and solve problems.
The toddler loves to imitate the people in their life. Much of the toddler’s behavior is replication
of what is heard and seen in the environment. The toddler also learns through repetition. For
example, they may want the same book at bedtime night after night, staying engrossed in the
story every time.
A toddler also likes order and often responds with dif culty to disruption in routine. The level of
response is related to the temperament of the child. Some toddlers may revolt with temper
tantrums, and others will calmly transition into an experience. Regardless of temperament, most
children at this stage respond favorably to predictable routines.
● Language development
Language Development
With increasing cognitive development, toddlers can listen to and understand short explanations.
This is a time when the child develops a more understandable language system. Language is
about ful lling needs: “I do” or “want drink.” The toddler moves from using single words to
short phrases. Some parents worry when their child does not fall exactly within what are
considered normal language parameters. The nurse can reassure parents that it is important to
assess what the child understands and what the child is able to communicate, with or without
words, rather than exact correctness in pronunciation.
● Psychosocial development
Psychosocial Development
Toddlers typically exemplify characteristics of Freud’s anal stage. The child begins to develop a
sense of self as separate from the mother. The toddler’s task is to move away from the primary
caregiver while maintaining enough connection to feel secure. This process, called
rapprochement, is healthy and expected.
Toddlerhood also corresponds with Erikson’s stage of autonomy versus shame and doubt. It is a
time when the child makes every effort to “do it myself.” Mastery is an extremely important task
of this stage of development. Because the toddler’s abilities begin to surpass cognitive judgment,
it is also a time of potential hazard for the developing child. Caregivers must walk the ne line
between allowing exploratory independence and “mastery” on one hand and vigilance on the
other. It is often a time of bumps and “booboos.”
Often dubbed as the “terrible twos,” this entire stage can be a tumultuous time for both
caregivers and toddlers. The child must begin to internalize behavioral standards at a time when
establishing independence is important. The nurse can help parents understand that the toddler
does not set out to make life miserable. The toddler simply has few internal mechanisms in place
to accomplish what needs to be done safely. It is frustrating to the toddler when confronted with
blocks to budding mastery. The word “no” begins to signify the toddler’s simple response to
frustrated emotions encountered.
● Moral development
Moral Development
Cognitively, the toddler is still a very concrete thinker and knows that something is “good” or
“bad” but does not know why. At this stage, the toddler identi es good and bad and right and

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wrong by virtue of whether it is rewarded or punished. This corresponds to Kohlberg’s
preconventional level of moral development.
● Discipline
Discipline
The purpose of discipline is to teach the child socialization and safety. It is the responsibility of
the parent to provide a rm structure so the toddler can explore the world while offering safe
limits (Box 13-5). Many children repeatedly test rules while also unconsciously learning to rely
on the security those limits provide. Having a structured environment for the child does not
necessarily mean it is rigid or in exible. Parents must learn to structure the toddler’s
surroundings to allow enough exibility to test limits.
A child at this stage needs guidance to determine how to act appropriately. The toddler thinks
concretely and must rely on others to help give realistic parameters. Some parameters may create
a great deal of con ict when what the toddler is allowed to do does not match what the toddler
wants to do, which may result in a temper tantrum. Praise becomes an excellent component of
discipline because most children want to please the parent.
● Temper tantrums
Temper Tantrums
Because this is a time of intense exploration and discovery and the toddler is establishing a sense
of self as a competent doer, there will be bumps in the road (Fig. 13-5). A tantrum is a normal
way of working things out internally for the toddler. Parents and caregivers need to know that
tantrums are normal for the toddler. It may be possible for parents to anticipate when tantrums
are most apt to occur (e.g., when the toddler is tired, hungry, or overwhelmed by new situations,
reserves are low, and therefore, the toddler may be more likely to explode or “melt down”).
Tantrums may be avoided or minimized if anticipated. Get a tired child to rest or feed a hungry
child to decrease their frustration level. The nurse can teach the parents coping strategies to use
when tantrums do occur. When the child is wailing and thrashing but not doing any harm, ignore
them. Often this is not possible, and it may be necessary for the parent to intervene quickly and
decisively to remove the child to a quieter or safer place. Touching and distractions may help
soothe a tantrum for one child. Another child may need to continue the tantrum under the
watchful eye of the parent. The latter requires that the parent be present but not engaged in direct
communication with the child. The goal is for the child to feel (and be) safe without being
negatively or positively reinforced for having a tantrum.
● Anticipatory guidance
Anticipatory Guidance
The increasingly mobile toddler challenges parents and care-givers to keep them safe at all times.
Constant supervision is required. As the toddler actively explores the environment, they do so
with little understanding of the consequences of their actions. Cabinet doors must have child-safe
locks, mini-blind cords must be secured above the reach of the toddler to prevent asphyxiation,
and windows and doors must be locked. As the older toddler learns to ride a tricycle, teach the
importance of wearing a helmet.
The toddler is beginning to learn about rules and consequences. Consistency in how those rules
and consequences are applied is very important. Discipline must be appropriate to the rule
broken. Providing a toddler with a brief time-out is a very effective disciplinary tool. It is
important to choose a safe place for the time-out, such as a chair in a visible area of a room. A
general rule of thumb for time-outs with toddlers is 1 minute per year of age. Box 13-6 discusses
additional anticipatory guidance guidelines for the toddler.

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 Early Childhood (Preschooler) (3-6 Years)

● Physical development
Physical Development
Children at this age come in various sizes, shapes, and body types. As a rule, the preschooler
begins to grow taller and thinner. The abdomen will atten as the child grows. The abdominal
muscles strengthen and the pelvis straightens. The physical growth rate for this stage of
development is slow but steady. The average weight gain of the preschooler is about 5 pounds (2
kg), and growth is 2.5 to 3 inches (6.3– 7.6 cm) per year. By age 4, the child’s posture straightens
and the child is able to move around in a more balanced fashion. As muscles become more
developed, the preschooler becomes stronger. The face narrows, the nose enlarges, and the skin
becomes more adult-like.
The preschooler is much more agile. At age 4, the preschooler can ride a tricycle and climb up
and down the stairs comfortably using alternating feet. The preschooler can also skip and hop
and is much more coordinated on the balance beam.
Fine motor skills rely on the use of the fore nger and the thumb. As the brain becomes more
developed, they are better able to pick things up with the ngers. Hand dominance begins to
develop around the age of 3 when the preschooler may show a preference in using one hand over
the other. By the age of 4, that preference is established (Table 13-7).
● Cognitive development
Cognitive Development
This period of development corresponds with Piaget’s pre-operational stage (2–4 years). During
this time, the pre-schooler increases the ability to verbalize. The preschooler can symbolically
use language to represent concepts that need to be conveyed. The young child is still egocentric
(focused only on their own sense of things) and therefore is limited socially. This is in large part
because of concrete thinking processes and the inability to abstractly shift focus from self to
others. The preschooler is also not able to transfer attention from one aspect of an object to
another (e.g., a child at this stage can identify a dog’s collar but is not able to describe its texture)
(Fig. 13-6).
● Language development
Language Development
The preschooler has increased ability to verbalize; vocabulary increases from 1,500 to 2,000
words between the ages 3 and 5. The preschooler uses sentences and is much more able to
convey an intended message. When the young child is able to use words, tantrums generally
begin to subside. The pre-schooler loves silly words and rhymes and asks many questions,
generally those that begin with “why?” To meet the needs of the preschooler, keep answers
simple and avoid giving too much information. Bombarding the preschooler with overwhelming
answers can be disconcerting for the child. The nurse can tell the parent that a preschooler may
stutter as they try to get out all of the words faster than they are able to speak them. Stuttering
generally resolves quickly.
● Psychosocial development
Psychosocial Development
Early childhood is a wonderful time marked by the exploration of new skills and the ability to
nally gure out how to get and do things for oneself. As the preschooler develops, they are
presented with many situations to truly excel. The preschooler has learned many new skills and
is becoming a “big kid.” The preschooler enjoys positive feedback for accomplishments. The fact

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 that the preschooler can do many new things creates a dilemma, and the preschooler must decide
which things are most important. Parents may not approve of the decisions made by the
preschooler, and the child may become con icted when limits are set. Often the preschooler
ponders about doing “the right thing” or doing “the wrong thing” and risking the parent’s dismay.
Conscience develops and begins to guide the child through the maze of “wants” versus “cans.”
The preschool child displays a good deal of magical thinking. For example, if they imagine
something bad happening and that event actually occurs, the preschooler will believe that their
thinking caused the outcome.
Freud described this period as the phallic or oedipal period. The child is becoming more aware of
gender differences. The female preschooler may want to marry dad or the boy in preschool rather
than relate to her best female friend.
Family is very important to the preschooler. However, the preschooler is now discovering the
joys of friendships. The young child looks to their peers for new ideas and information and
begins to develop an understanding of what it means to be kind. The preschooler is more social
and is often more willing to share toys with others than when they were a toddler.
● Moral development
Moral Development
Early childhood typically corresponds with Kohlberg’s pre-conventional morality stage when the
major impetus for moral judgment is to avoid punishment. It is common for the child in this age
group to tell lies to avoid consequences. A child at this age may judge an action to be wrong only
if caught. The young child is only guilty if the parent has seen the actions.
● Discipline
Discipline
Because the preschooler is beginning to understand that actions have consequences, caregivers
can take advantage of this understanding. The preschooler knows that there are rules and that not
obeying those rules leads to consequences. It is best if rules are explained before infractions
occur. At the very least, rules must be explained before disciplining the child. This helps the
preschool child learn more clearly how to behave. Consequences can, as much as possible,
follow naturally and t the behavior being punished (e.g., having the child clean up their own
mess or miss a favorite television show if they dawdle).
As with toddlers, a typical discipline strategy instituted with preschoolers is providing the child
with a time-out. A rule of thumb is a minute time-out per year of age. Whether that time-out is in
a speci ed chair or section of the room, it is important to help the child know that the purpose of
the time-out is to calm themself and to shift gears and act appropriately.
Many parents begin using behavioral charts at this age to praise positive behavior and to help the
preschooler understand what is expected and to be rewarded when “good” behavior is shown.
For many preschoolers, simply getting a star or sticker on the chart is reward enough to
encourage good behavior. For others, a more sophisticated measure of rewards is needed, such as
allowing additional television time or a favorite activity. The goal of discipline and limit-setting
at this stage of development is to begin teaching the preschooler to regulate their own behavior.
● Anticipatory guidance
Anticipatory Guidance
The preschooler has much to learn in these years. Parents can assist in language development and
comprehension by reading and singing to the preschooler each day. It is important to praise the
child’s accomplishments to build con dence and a sense of achievement. Parents can expect the

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 preschooler to test limits. It becomes increasingly important for parents to set and maintain
consistent limits on behavior and provide appropriate discipline (Box 13-7).
Many parents ask how they will know their preschooler is ready to begin kindergarten. Mastery
of skills before and including the preschool years prepares the child to start school. Preschools
and child care programs provide opportunities for the preschooler to interact with other children,
learn cooperative play, and enhance cognitive, language, social, and physical skills. Working
closely with the teachers in these early childhood programs gives parents the information they
need to assess when their child is ready to begin school.

School-Age (6-12 Years)

● Physical development
Physical Development
Early in this stage, boys and girls follow similar growth trajectories. Both begin to grow taller
and further lose their baby fat. Children at this age gain about 4 to 6 pounds (1.8–2.7 kg) and
grow 2 inches (5 cm) per year. As abdominal muscles strengthen, posture straightens. Facial
features become more re ned. Still, there are many variations in size and shape of children in
this period. These variations are in uenced not only by familial and cultural genetics but also by
environmental factors (e.g., diet and exercise).
Most school-age children begin to develop axillary sweating. In girls, hips begin to broaden and
the pelvis widens in preparation for childbearing. Breasts begin to enlarge and become tender.
The vaginal pH changes from alkaline to acidic, and the vagina develops a thick mucoid lining.
Pubic hair begins to develop between the ages of 8 and 14. While menarche can begin as early as
8 to 10 years of age, the average age in the United States is 12 years of age.
Boys also begin sexual development at these ages. Their bodies become more muscular. Between
10 to 12 years of age, the testes become more sensitive to pressure, the skin of the scrotum
darkens, and pubic hair begins to develop. Boys often experience gynecomastia, a temporary
enlargement of breasts as a result of hormonal shifts. This can be embarrassing, and the child and
family need reassurance of its transient nature.
Both males and females are assessed at well-child visits using the Tanner staging of development
of secondary sex characteristics. Tanner staging is done to document evidence of normal pubertal
development for the age of the child, and it is an important assessment to detect signs of sexual
abuse and precocious puberty (Table 13-8).
At this age, it is important to guard the child’s privacy. As a nurse, be aware of self-conscious
behavior related to physical changes occurring in the body. Along with privacy, the nurse must be
aware of other issues affecting the child and family related to menstruation, secondary sexual
characteristics, hormone imbalances, mood swings, and social needs, as well as other speci c
areas identi ed by the child and family.
● Cognitive development
Cognitive Development
The school-age child is better able than the younger child to use logical thinking. This logic in
thinking corresponds with Piaget’s Concrete Operations stage of cognitive development. While
the child’s thinking is still quite concrete, they can begin to solve problems. During this
childhood stage, they begin to replace the ever-present “why?” question with “how?” Mastery is
focused on guring out how things work. The school-age child builds on experience and begins
to recognize consequences of actions. In school, they work on tasks requiring awareness of space
(where things are in relation to other things), causality (logical consequences), categories (how

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 things t together), conservation (physical quantity can remain constant even when state is
altered), and numbers. They are also capable of metacognition, the ability to think about
thinking. At this age, the child is aware of their own thinking and can assess how he came to
conclusions, a process that eventually leads to critical thinking.
Memory deepens as the child grows. They become more adept at processing and working
through information. Memory improves because the brain retains more information. A child in
this age group is also better able to determine what is important to remember and what is not.
This helps them lter out irrelevant data, leaving memory space available.
● Language development
Language Development
Language improves considerably. The child uses words more accurately, particularly verbs,
metaphors, and similes. The child can elaborate on concepts that they want to express.
● Psychosocial development
Psychosocial Development
There is vast emotional growth during the middle child years. Erikson described this stage as one
of industry versus inferiority. Unlike the younger child who believes they can do almost
anything, the 6- to 10-year-old child begins to assess what they can and cannot accomplish.
School-age children need and seek praise. They have a more de nite sense of self-esteem or
competence based on the ability or lack of ability to perform.
Early in the middle childhood period (ages 6–9), the child is still self-focused. The school-age
child continues to exhibit magical thinking, in that they still may feel responsible for bad things
that happen. Later in this stage (ages 9–12), the child is increasingly independent, although they
want approval and validation. Throughout this stage, sorting, collecting, and board games are
common activities. Competing and winning become important in the growing sense of self-
competence. Friendships are exceptionally important at this stage. The school-age child looks
more to friends than family, but family is still important. Best friends tend to be of the same
gender, although mixed gender groups of school-age children become common as they reach the
pre-teen and early teen years (Fig. 13-7).
● Moral development
Moral Development
For the rst several years, the school-age child is still operating within preconventional morality.
The younger child sees things as black and white and as self-referenced, rather than connected
with more generalized rules and concepts. By the age of 10, the child enters Kohlberg’s
conventional morality stage. During this time, the child has internalized rules and is intently
gaining approval. The older child operates within a morality of cooperation that implies
recognition of the interaction between the self and a “bigger” worldview. Most children at this
age are motivated to adhere to laws as a way to keep order.
● Discipline
Discipline
Because the child in this stage of development is beginning to internalize rules, it is important to
allow the child more independence and thus more awareness of the natural consequences of
behavior. An effective parental technique is to refrain from “rescuing” the child from the
consequences of their behavior (e.g., rushing home to retrieve a forgotten piece of homework
whenever the child calls rather than allowing them to learn a valuable lesson).
While many school-age children respond appropriately to natural consequences, some do not yet
understand responsibility. In fact, most children opt at some time to ignore natural consequences.

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 Parents may need to impose the previously discussed time-out strategy (e.g., grounded for a
period of time or privileges restricted).
● Anticipatory guidance
Anticipatory Guidance
The school-aged child experiences many physical changes that can be confusing and frightening.
Many parents are uncomfortable discussing, or unsure how to discuss, pubertal changes and need
information to help them explain these changes to their child. Educating the parents and child
about these changes before they occur is important. Many elementary and middle schools invite
parents to view the materials taught in health classes regarding puberty and physical changes.
Nurses can encourage parents to review those materials and give permission for their child to
receive that information in class and then reinforce it at home (Box 13-8).

Adolescence (12-19 Years)

● Physical development
Physical Development
Adolescence technically begins with the onset of puberty when the pituitary gland relays
messages to sex glands to manufacture hormones necessary for reproduction. It is a period of
great growth, second only to infancy. While the growth rate is not as dramatic as that of the
earlier stage, it is still signi cant. It is not unusual for girls to gain 15 to 55 pounds (6.8–25 kg)
and grow 2 to 8 inches (5–20 cm) and boys to gain 15 to 66 pounds (6.8–30 kg) and grow 4 to 12
inches (10–30 cm) before they reach maturity. Girls develop earlier than boys and tend to have a
smaller over-all physical structure. Both boys and girls develop primary and secondary sex
characteristics at this stage. The timing of development is variable (Table 13-9).
● Cognitive development
Cognitive Development
Adolescence corresponds with Piaget’s formal operational stage. The adolescent can think
abstractly and use logic to solve problems and to test out hypotheses. In addition, they use
deductive reasoning and can think about thinking. An individual in this age group begins to be
concerned with such things as philosophy, morality, and social issues. The adolescent can project
thoughts over the long term, thus making plans and setting life goals. They often compare beliefs
with those of peers.
● Language development
Language Development
By adolescence, the child has highly developed and sophisticated language skills. They have the
ability to speak and write correctly. The adolescent is also able to communicate and debate
alternative points of view.
● Psychosocial development
Psychosocial Development
According to Erikson, the adolescent crisis is concerned with identity versus role confusion. The
adolescent must begin to identify who she is and who she will be in life. One of the major
sources of in uence over an adolescent is the peer group (Fig. 13-8). Members of the peer group
offer differing viewpoints, allow for the establishment of strong relationships, and provide the
opportunity for the adolescent to practice adult behaviors by becoming active within a social
group and increasingly self-suf cient. Three major issues must be confronted by the adolescent:
selecting an occupation, establishing and subscribing to a set of values, and developing a

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 satisfactory sexual identity. As the adolescent makes these important decisions, they become
more con dent in their abilities and gradually develops a sense of self.
● Moral development
Moral Development
At this stage, con icts emerge between what the adolescent has believed to be right or wrong and
what others may believe. This is a time of great questioning and consternation as the adolescent
learns that it is possible for several views of morality to exist. Kohlberg de ned this stage as
post-conventional morality.
● Discipline
Discipline
The adolescent is at the stage where they begin to internalize responsibility for behavior. Parental
input and guidance are still needed in terms of rules (e.g., curfew, homework, chores, etc.) and
possible consequences for infractions, but adolescents are much more able than children in any
previous stage to monitor and regulate actions based on critical thinking. It is important in this
stage, as in all others, that the parent focus on the positives of the adolescent’s behavior. Natural
consequences are powerful motivators, but by this time, the adolescent may have learned that
they can avoid consequences by being crafty. Removing privileges may be an effective
consequence for the adolescent’s poor decision-making.
● Anticipatory guidance
Anticipatory Guidance
The adolescent is deeply in uenced by the peer group. They spend a great deal of time with their
peers, often foregoing family activities in favor of time with friends. Depending on the peer
group, teens may experience peer pressure to drink alcohol, smoke, experiment with illicit drugs,
or engage in sexual activity. Parents must keep the lines of communication with their adolescent
open and talk about how to resist peer pressure. It is important for the adolescent to identify a
trusted adult with whom they can talk about sensitive issues and get advice (Box 13-9).

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17
 1. A nurse is assessing a newborn’s re exes. Which of the following is a normal re ex found at
birth
a) Babinski
b) Stepping
c) Rooting
d) Grasping

2. A 2-year-old child is brought in for a check-up. According to Erikson, which stage of

psychosocial development is the child in
a) Trust vs. mistrust
b) Autonomy vs. shame and doubt
c) Initiative vs. guilt
d) Industry vs. inferiority

3. Which statement about Piaget’s cognitive development theory is accurate for a 7-year-old
child
a) The child can perform abstract reasoning.
b) The child can solve problems using logic but only in concrete terms.
c) The child relies solely on sensory input to understand the world.
d) The child cannot understand cause-and-effect relationships.

4. During a well-baby visit, the nurse explains to the parents that their infant’s development
follows a cephalocaudal pattern. What does this mean
a) Development occurs from the feet upward.
b) Development proceeds from the head downward.
c) Growth starts in the arms and legs rst.
d) Fine motor skills develop before gross motor skills.

5. At what age does an infant typically achieve object permanence, according to Piaget’s theory
of cognitive development
a) 6 months
b) 12 months
c) 9 months
d) 18 months

6. A 4-year-old child engages in magical thinking. According to Piaget, which stage of cognitive
development is this child in
a) Sensorimotor
b) Preoperational
c) Concrete operational
d) Formal operational

7. A nurse is assessing the ne motor skills of a 9-month-old infant. Which milestone should the
nurse expect the infant to have achieved
a) Crawling
b) Walking with support

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 c) Transferring objects from hand to hand
d) Pincer grasp

8. Which Eriksonian stage is the focus for an adolescent aged 13-18 years old
a) Trust vs. mistrust
b) Identity vs. role confusion
c) Initiative vs. guilt
d) Autonomy vs. shame and doubt

9. A 2-month-old infant is expected to demonstrate which of the following re exes

a) Moro re ex
b) Plantar grasp
c) Stepping re ex
d) Babinski re ex

10. A nurse is explaining anticipatory guidance to a group of parents. Which statement by a

parent indicates the need for further teaching
a) “I should start baby-proo ng my house when my baby starts crawling.”
b) “I will introduce solid foods when my baby is around 6 months old.”
c) “It’s normal for my baby to not recognize familiar people yet.”
d) “My baby should sleep on their back to prevent sudden infant death syndrome (SIDS).”

11. During an assessment, the nurse notes that a 4-year-old child is unable to share toys with
peers. According to Erikson’s stages, the child may be experiencing dif culty with which task
a) Trust vs. mistrust
b) Autonomy vs. shame and doubt
c) Initiative vs. guilt
d) Industry vs. inferiority

12. A parent is worried because their 1-year-old has not started walking yet. What is the most
appropriate response by the nurse
a) “Your child should be walking by now. We need to refer you to a specialist.”
b) “Many children do not walk until 18 months, so there’s no need to worry right now.”
c) “Walking typically begins at 9 months, so this may be a developmental delay.”
d) “Every child develops at their own pace. Let’s monitor your child’s progress closely.”

13. At what age can an infant typically roll over completely

a) 2 months
b) 4 months
c) 6 months
d) 9 months

14. Which of the following should the nurse include when discussing the psychosocial
development of a preschooler
a) Children at this age struggle with autonomy and shame.
b) Preschoolers often experience role confusion.

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 c) Preschoolers are learning how to initiate tasks without feeling guilty.

d) Preschoolers are focused on building trust in relationships.

15. During a routine visit, the parents of a 5-year-old express concern about their child’s
dif culty with cooperative play. What is the nurse's best response
a) “Children develop cooperative play by the time they are 6 to 7 years old.”
b) “Cooperative play typically develops around 2 to 3 years of age.”
c) “This could indicate a developmental delay, and we may need to investigate further.”
d) “Children typically begin cooperative play between 4 to 5 years of age.”

16. According to Kohlberg’s stages of moral development, at what stage is a child likely to
conform to rules to avoid punishment
a) Preconventional
b) Conventional
c) Post-conventional
d) Formal operational

17. At what age should the nurse expect a child to achieve bowel and bladder control, signaling
readiness for toilet training
a) 12-18 months
b) 24-36 months
c) 48-60 months
d) 6-9 months

18. A nurse is reviewing the growth chart of a 2-year-old child. The child’s weight has doubled
since birth. What is the most appropriate action by the nurse
a) Reassure the parents that this is normal growth.
b) Refer the child for further evaluation of failure to thrive.
c) Encourage the parents to increase caloric intake.
d) Ask the parents if there have been any dietary restrictions.

19. Which developmental task is expected for an infant at 6 months of age

a) Sitting without support
b) Babbling
c) Standing with assistance
d) Walking independently

20. A parent asks when their child will begin to develop secondary sex characteristics. The nurse
should respond by stating that secondary sex characteristics typically begin
a) Between ages 8-12
b) Between ages 6-8
c) Between ages 5-6
d) Between ages 10-14

21. At what age should a nurse expect a child to begin using two-word sentences, such as “want
juice”

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 a) 12 months
b) 18 months
c) 24 months
d) 30 months

22. A 9-year-old child is mastering school tasks and homework. Which of Erikson's psychosocial
stages is the child likely experiencing
a) Trust vs. mistrust
b) Autonomy vs. shame and doubt
c) Initiative vs. guilt
d) Industry vs. inferiority

23. Which of the following best demonstrates the concept of proximodistal development in a
child
a) A child learns to walk before learning to run.
b) A child gains control of their arms before their hands.
c) A child speaks before understanding full sentences.
d) A child learns to balance on one foot before walking.

24. A nurse is assessing a 15-year-old adolescent. According to Piaget, which cognitive milestone
should the adolescent have achieved
a) Use of logic and reasoning
b) Ability to perform abstract thinking
c) Object permanence
d) Understanding conservation

25. A parent expresses concern that their 7-year-old child is starting to feel inadequate compared
to classmates. The nurse should assess whether the child is struggling with which of Erikson's
stages
a) Autonomy vs. shame and doubt
b) Industry vs. inferiority
c) Identity vs. role confusion
d) Initiative vs. guilt

26. At what age does the Moro re ex typically disappear in infants

a) 1 month
b) 3 months
c) 6 months
d) 9 months

27. Which of the following indicates a 4-month-old infant is developing normally

a) Crawls on hands and knees
b) Rolls from back to front
c) Sits without assistance
d) Stands with support

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 28. Which developmental milestone is expected for a 2-year-old child

a) Walks upstairs with alternating feet
b) Rides a tricycle
c) Kicks a ball
d) Hops on one foot

29. A nurse is educating parents about temper tantrums in their 2-year-old. Which of the
following is the most appropriate teaching
a) “Temper tantrums indicate emotional instability.”
b) “Temper tantrums are a normal developmental stage.”
c) “Temper tantrums are a sign of cognitive delay.”
d) “Temper tantrums should be punished immediately.”

30. A nurse is observing an infant for gross motor development. By what age should the nurse
expect the infant to sit without support
a) 4 months
b) 6 months
c) 8 months
d) 12 months

31. Which of the following toys is most appropriate for a 6-month-old infant
a) A stuffed animal
b) A rattle
c) A coloring book
d) A small ball

32. A 4-year-old is being assessed for language development. Which skill should the nurse
expect the child to demonstrate
a) Babbling simple sounds
b) Speaking in complete sentences
c) Naming at least two body parts
d) Saying one-word phrases

33. Which re ex is expected to be present in a 2-week-old infant but not in a 9-month-old infant
a) Babinski
b) Sucking
c) Moro
d) Rooting

34. The nurse is explaining to a group of parents how toddlers learn best. Which of the following
learning methods should the nurse emphasize
a) Through structured play
b) Through repetition and imitation
c) Through abstract reasoning
d) Through rewards and punishments

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 35. A 6-year-old is in the early stages of learning to read. According to Erikson, which
developmental task is the child currently facing
a) Initiative vs. guilt
b) Autonomy vs. shame and doubt
c) Industry vs. inferiority
d) Identity vs. role confusion

36. A nurse is caring for a 10-month-old infant. Which of the following would indicate the need
for further assessment of development
a) Babbling and making sounds
b) Crawling
c) Pulling to stand
d) Unable to roll over

37. Which of the following behaviors would be expected from a toddler in the autonomy vs.
shame and doubt stage
a) Insisting on choosing their own clothes
b) Seeking constant reassurance from parents
c) Expressing a fear of failure in new tasks
d) Imitating adult behaviors

38. At what age does Piaget's preoperational stage of development begin

a) 2 years
b) 4 years
c) 6 years
d) 7 years

39. A nurse is assessing a 4-year-old child’s play behavior. Which type of play is most common
at this age
a) Solitary play
b) Parallel play
c) Cooperative play
d) Associative play

40. The nurse is discussing moral development with a group of parents. Which of the following
stages would a 6-year-old child be in, according to Kohlberg
a) Preconventional
b) Conventional
c) Post-conventional
d) Formal operational

41. Which motor skill would the nurse expect a 5-month-old infant to achieve
a) Grasping objects
b) Walking with assistance
c) Stacking blocks
d) Turning pages in a book

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 42. A nurse is providing anticipatory guidance to the parents of a preschooler. Which of the
following should the nurse emphasize regarding psychosocial development
a) Preschoolers often demonstrate independence through self-care tasks.
b) Preschoolers should have well-developed logical reasoning.
c) Preschoolers typically engage in solitary play.
d) Preschoolers should have completely developed ne motor skills.

43. A parent expresses concern that their 18-month-old toddler is not talking yet. Which of the
following should the nurse advise
a) “This is normal, but you should encourage more verbal interaction.”
b) “Toddlers typically start talking around 12 months.”
c) “It would be helpful to schedule a speech evaluation.”
d) “You should wait until age 3 to worry about speech development.”

44. A nurse is assessing the social development of a 9-month-old infant. Which behavior would
be expected
a) Stranger anxiety
b) Separation anxiety
c) Object permanence
d) Parallel play

45. At what age does an infant typically begin to smile socially

a) 1 month
b) 2 months
c) 4 months
d) 6 months

46. Which of the following motor skills is expected for a child between the ages of 4 to 5 years
a) Holding a crayon with a st
b) Cutting shapes with scissors
c) Turning pages one at a time
d) Building a tower of four blocks

47. At which of Piaget’s cognitive stages does a child begin to think abstractly and use logic to
solve problems
a) Sensorimotor
b) Preoperational
c) Concrete operational
d) Formal operational

48. Which of the following would be considered a red ag in the development of a 3-year-old
child
a) Unable to ride a tricycle
b) Unable to speak in short sentences
c) Unable to share toys

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 d) Unable to count to 10

49. A 6-year-old child engages in sorting and collecting objects. According to Piaget, which
cognitive milestone does this re ect
a) Symbolic thinking
b) Abstract reasoning
c) Conservation
d) Logical ordering

50. A 4-year-old child is brought to the clinic because the parent is concerned about their child’s
fantasy play. What should the nurse tell the parent
a) “This is normal and part of imaginative development.”
b) “Fantasy play may be a sign of an underlying issue.”
c) “You should encourage your child to stop fantasizing.”
d) “This may be a developmental delay requiring further evaluation.”

Answers
1. c) Rootin
2. b) Autonomy vs. shame and doub
3. b) The child can solve problems using logic but only in concrete term
4. b) Development proceeds from the head downwar
5. c) 9 month
6. b) Preoperationa
7. c) Transferring objects from hand to han
8. b) Identity vs. role confusio
9. a) Moro re e
10. c) “It’s normal for my baby to not recognize familiar people yet.
11. c) Initiative vs. guil
12. d) “Every child develops at their own pace. Let’s monitor your child’s progress closely.
13. c) 6 month
14. c) Preschoolers are learning how to initiate tasks without feeling guilt
15. d) “Children typically begin cooperative play between 4 to 5 years of age.
16. a) Preconventiona
17. b) 24-36 month
18. b) Refer the child for further evaluation of failure to thriv
19. b) Babblin
20. a) Between ages 8-1
21. c) 24 month
22. d) Industry vs. inferiorit
23. b) A child gains control of their arms before their hand
24. b) Ability to perform abstract thinkin
25. b) Industry vs. inferiorit
26. b) 3 month
27. b) Rolls from back to fron
28. c) Kicks a bal
29. b) “Temper tantrums are a normal developmental stage.

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 30. c) 8 month
31. b) A rattl
32. b) Speaking in complete sentence
33. c) Mor
34. b) Through repetition and imitatio
35. c) Industry vs. inferiorit
36. d) Unable to roll ove
37. a) Insisting on choosing their own clothe
38. a) 2 year
39. c) Cooperative pla
40. a) Preconventiona
41. a) Grasping object
42. a) Preschoolers often demonstrate independence through self-care tasks
43. a) “This is normal, but you should encourage more verbal interaction.
44. a) Stranger anxiet
45. b) 2 months
46. b) Cutting shapes with scissor
47. d) Formal operationa
48. b) Unable to speak in short sentence
49. d) Logical orderin
50. a) “This is normal and part of imaginative development.”

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