A nurse is completing an assessment of a 2-month-old. Which of the following developmental skills is an expected finding?

Grasps objects

Follows objects with eyes

Laughs and squeals

Rolls from back to side

Answer and Explanation

The Correct Answer is B

A. At 2 months old, infants typically do not have the fine motor skills necessary to grasp objects intentionally. This skill usually develops around 4 to 6 months of age.
B. By 2 months of age, infants are expected to follow objects with their eyes as their visual tracking improves. This is a normal developmental milestone for this age.
C. Laughing and squealing are typically seen later, around 4 to 6 months of age. At 2 months, infants may coo and make other vocalizations but not laugh or squeal.
D. Rolling from back to side usually begins around 4 to 6 months of age. At 2 months, infants are generally not yet capable of this movement.

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Correct Answer is C

Explanation

A. The largest fetal diameter passing through the pelvic outlet would indicate that the fetus has progressed further down the birth canal, beyond 0 station. This usually corresponds to a positive station, where the presenting part is below the ischial spines.
B. The palpation of the posterior fontanel refers to the position of the fetal head, which is not directly related to the station. Station is about the level of the presenting part relative to the ischial spines, not specific to fontanel palpation.
C. A 0 station indicates that the presenting part of the fetus, typically the head in a cephalic presentation, is at the level of the ischial spines. This is a key landmark in labor progression, signifying that the fetal head is engaged in the pelvis.
D. The left occiput posterior (LOP) position refers to the orientation of the fetal head relative to the maternal pelvis, not the station. Station is about the descent of the presenting part, not its orientation.

A. 3-0-2-0-2 B. 4-0-1-2-2 C. 2-0-0-2-0 D. 4-2-0-2-2

Correct Answer is D

Explanation

A. This option does not accurately reflect the client's history.
The client has had two term deliveries (twins), one preterm delivery (spontaneous abortion at 15 weeks), and is currently pregnant.
B. The numbers do not correspond with the provided pregnancy history.
C. The option does not account for the number of term deliveries or preterm deliveries accurately.
D. The client’s GTPAL status is:
- G: 4 (total pregnancies, including current one)
- T: 2 (twins born at 36 weeks)
- P: 0 (no preterm deliveries, as 36 weeks is not considered preterm)
- A: 2 (elective abortion at 9 weeks and spontaneous abortion at 15 weeks)
- L: 2 (living children from the twins).

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A nurse is completing an assessment of a 2-month-old. Which of the following developmental skills is an expected finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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