1
Q
- Which of the following is most consistent with a
normal developmental examination for a 3-month-old
infant born at 40 weeks’ gestation?
A. sitting briefly with support
B. experimenting with sound
C. rolling over
D. having a social smile
A
B
2
Q
- Which of the following is most consistent with a
normal developmental examination for a thriving
5-month-old infant born at 32 weeks’ gestation?
A. sitting briefly with support
B. experimenting with sound
C. rolling over
D. performing hand-to-hand transfers
A
B
3
Q
18. A healthy full-term infant at age 3 to 5 months should be able to: A. gesture to an object. B. bring hands together. C. reach for an object with one hand. D. feed self a teething biscuit.
A
B
4
Q
19. A healthy infant at age 9 to 11 months is expected to: A. roll from back to stomach. B. imitate “bye-bye.” C. play peek-a-boo. D. hand toy on request.
A
C
5
Q
- A healthy 2-year-old child is able to:
A. speak in phrases of two or more words.
B. throw a ball at a target.
C. scribble spontaneously.
D. ride a tricycle.
A
A
6
Q
21. At which age would a child likely start to imitate housework? A. 18 months B. 24 months C. 30 months D. 36 months
A
A
7
Q
22. A healthy 3-year-old child is expected to: A. give his or her first and last name. B. use pronouns. C. kick a ball. D. name a best friend.
A
A
8
Q
23. A healthy 6- to 7-month-old infant is able to: A. roll from back to stomach. B. confidently feed self a cracker. C. reach for an object. D. crawl on abdomen.
A
A
9
Q
- You examine a healthy 9-month-old infant from a
full-term pregnancy and expect to find that the
infant:
A. sits without support.
B. cruises.
C. has the ability to recognize his or her own name.
D. imitates a razzing noise.
A
C
10
Q
- A healthy 3-year-old child is in your office for
well-child care. You expect this child to be able to:
A. name five colors.
B. alternate feet when climbing stairs.
C. speak in two-word phrases.
D. tie shoelaces.
A
B
11
Q
- Which of the following would not be found in
newborns?
A. best vision at a range of 8 to 12 inches
B. presence of red reflex
C. light-sensitive eyes
D. lack of defensive blink
A
D
12
Q
- Which of the following do you expect to find in an
examination of a 2-week-old infant?
A. a visual preference for the human face
B. a preference for low-pitched voices
C. indifference to the cry of other neonates
D. poorly developed sense of smell
A
A
13
Q
- Which of the following is the most appropriate
response in a developmental examination of a healthy
5-year-old child?
A. being able to name a best friend
B. giving gender appropriately
C. naming an intended career
D. hopping on one foot
A
A
14
Q
- You are examining an 18-month-old boy who is not
speaking any discernible words. Mom tells you he has
not said “mama” or “dada” yet or babbled or smiled
responsively. You:
A. encourage the mother to enroll her son in day care
to increase his socialization.
B. conduct further evaluation of milestone
attainment.
C. reassure the parent that delayed speech is common
in boys.
D. order audiogram and tympanometry.
A
B
15
Q
30. The following benchmarks indicate normal development by a healthy child born at term who is now 12-months of age. (Choose all that apply.) A. talking in two-word sentences B. pointing to a desired object C. reaching for a desired object D. walking backward
A
B, C
16
Q
- It is considered a developmental “red flag” if a child
does not respond to his or her name by nine months
of age.
A. true
B. false
A
B
17
Q
- Which of the following children demonstrates a
developmental “red flag”?
A. a 14-month-old who only says “mama” and “no”
B. a 4-month-old who does not smile
C. a 12-month-old who does not respond to his/
her name
D. a 2-year-old who speaks two-word phrases
A
C
18
Q
- All of the following are consistent with a fragile X
syndrome diagnosis in males except:
A. microorchidism following onset of puberty.
B. large body habitus.
C. large ears.
D. hyperactivity
A
A
19
Q
- Which of the following chromosomal syndrome is a
common etiology of social and verbal developmental
delays in boys?
A. Tay-Sachs disease
B. cystic fibrosis
C. fragile X
D. trisomy 18
A
C
20
Q
35. One physical sign of fragile X syndrome in males includes: A. large eyes. B. large forehead. C. small head. D. recessive jaw.
A
B
21
Q
36. Klinefelter syndrome (XXY male) is most commonly marked by: A. language impairment in males. B. fine motor delay in males. C. hip and breast enlargement in women. D. attention deficit disorder in males.
A
A
22
Q
- Klinefelter syndrome (XXY male) and risk for
having a child with this condition can be accurately
identified by which of the following? (Choose all that
apply.)
A. urine test
B. literacy assessment
C. amniocentesis
D. blood testing for carrier state
A
C, D
23
Q
- All of the following would support a diagnosis of
autism spectrum disorder except:
A. a failure to initiate or respond to a social interaction.
B. exhibiting extreme distress with small changes in
routines.
C. the symptoms are absent until child reaches
school age.
D. excessive touching of objects.
A
C
24
Q
The American Academy of Pediatrics (AAP) recommends routine screening for autism
A
between 18 and 24 months
25
There are two main types of ASD behaviors:
restrictive/repetitive behaviors and social
| communication/interaction behaviors.
26
Diagnostic and statistical Manual of Mental Disorders, 5th edition (DSM-5) criteria for ASD include the following:
1. Persistent deficits in social communication and social
| interaction across multiple contexts.
27
Diagnostic and statistical Manual of Mental Disorders, 5th edition (DSM-5) criteria for ASD include the following:
2. Restrictive, repetitive patterns of behavior, interests, or activities as manifested by at least 2 of the following:
(a) stereotyped or repetitive motor movements, use of
objects, or speech; (b) insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal/nonverbal behaviour; (c) highly restricted,
fixated interests that are abnormal in intensity or
focus; and (d) hyper- or hyporeactivity to sensory
input or unusual interests in sensory aspects of the
environment.
28
Diagnostic and statistical Manual of Mental Disorders, 5th edition (DSM-5) criteria for ASD include the following:
3. Symptoms must be present in the early developmental period.
29
Diagnostic and statistical Manual of Mental Disorders, 5th edition (DSM-5) criteria for ASD include the following:
4. Symptoms cause clinically significant impairment in
| social, occupational, or other important areas of current functioning.
30
Diagnostic and statistical Manual of Mental Disorders, 5th edition (DSM-5) criteria for ASD include the following:
5. These disturbances are not better explained by
| intellectual disability or global developmental delay.
31
Developmental “Red Flags”
in the Young Child
Persistent presence of ≥1 of the following
indicators warrants further evaluation:
• By 6 months: No big smiles or other warm, joyful
| expressions
32
Developmental “Red Flags”
in the Young Child
Persistent presence of ≥1 of the following
indicators warrants further evaluation:
• By 9 months: No back-and-forth sharing of sounds,
| smiles, or other facial expressions
33
Developmental “Red Flags”
in the Young Child
Persistent presence of ≥1 of the following
indicators warrants further evaluation:
• By 12 months: Lack of response to name
34
Developmental “Red Flags”
in the Young Child
Persistent presence of ≥1 of the following
indicators warrants further evaluation:
• By 12 months: No babbling or “baby talk”
35
Developmental “Red Flags”
in the Young Child
Persistent presence of ≥1 of the following
indicators warrants further evaluation:
• By 12 months: No back-and-forth gestures, such
| as pointing, showing, reaching, or waving
36
Developmental “Red Flags”
in the Young Child
Persistent presence of ≥1 of the following
indicators warrants further evaluation:
• By 16 months: No spoken words
37
Developmental “Red Flags”
in the Young Child
Persistent presence of ≥1 of the following
indicators warrants further evaluation:
• By 24 months: No meaningful two-word phrases
| that don’t involve imitating or repeating
38
Fragile X syndrome
is the most common known cause of autism in
| either gender and occurs in all racial and ethnic groups
39
Klinefelter syndrome (XXY male)
also is associated with developmental issues, mainly
| verbal in nature
40
```
39. At which of the following ages in a healthy infant’s life is parental anticipatory guidance about teething most helpful?
A. 1 to 2 months
B. 2 to 4 months
C. 4 to 6 months
D. 8 to 10 months
```
C
41
40. At which of the following ages in a healthy young
child’s life is parental anticipatory guidance about
temper tantrums most helpful?
A. 8 to 10 months
B. 10 to 12 months
C. 12 to 14 months
D. 14 to 16 months
B
42
41. At which of the following ages in a developmentally
on-target young child’s life is parental anticipatory
guidance about using “time out” as a discipline
method most helpful?
A. 12 to 18 months
B. 18 to 24 months
C. 24 to 30 months
D. 30 to 36 months
B
43
```
42. At which of the following ages in a young child’s life is parental anticipatory guidance about protection from
falls most helpful?
A. birth
B. 2 months
C. 4 months
D. 6 months
```
A
44
43. At which of the following ages in a developmental
on-target young child’s life is parental anticipatory
guidance about toilet-training readiness most
helpful?
A. 12 months
B. 15 months
C. 18 months
D. 24 months
C
45
44. At which of the following ages in a young child’s life
is parental anticipatory guidance about infant sleep
position most helpful?
A. birth
B. 2 weeks
C. 2 months
D. 4 months
A
46
```
45. At which of the following ages in a developmental
on-target young child’s life is parental
anticipatory guidance about sexual activity
most helpful?
A. 6 years
B. 8 years
C. 11 years
D. 14 years
```
C
47
46. At which of the following ages in a developmental
on-target young child’s life is parental anticipatory
guidance about substance abuse most helpful?
A. 8 years
B. 11 years
C. 14 years
D. 16 years
B
48
```
47. Recommended total daily screen time (i.e., television, computer, tablet, games, other) for a young child is:
A. 0–30 minutes.
B. 1–2 hours.
C. 2–3 hours.
D. >4 hours.
```
B
49
3-4 mo
* Grasps cube
* Reaches for objects
* Brings objects to mouth
* Raspberry sound
50
5 mo
* Back straight when pulled to sitting
* Bears weight on legs when standing
* Plays with feet
* Sits with support
51
6-8 mo
```
• Sits without support
• Scoops small object with rake grip; some
thumb use
• Hand-to-hand transfer
• Imitates “bye-bye”
• Stranger and separation anxiety begins
(6 mo) and increases during this time period
• Pulls feet into mouth
```
52
9-11 mo
```
• Crawls, pulling self forward by hands,
then creeps with abdomen off floor
• Stands initially by holding on to furniture,
later stands solo
• Imitates peek-a-boo and pat-a-cake
• Picks up small object with thumb and
index finger
```
53
10-15 mo
```
• Initially walks with help, progresses to
walking solo
• Neat pincer grasp
• Places cube in cup
• Hands over objects on request
• Builds tower of two bricks
```
54
15-20 mo
* Points to several body parts
* Throws a ball overhand
* Seats self in chair
* Climbs
55
3-4 mo
* Laughs, squeals, vocalizes in response to others
* Recognizes food by sight
* Rolls back to side
* Imitates others
* Repeats interesting actions
* Coughs, snorts to attract attention
56
6-8 mo
• Closes lips in response to dislike of food
• Rolls back to stomach and stomach to back
• Recognizes “no”
• Chains together syllables (dada, papa, mama) but
does not have meaning
57
9-11 mo
• Cruises
• Follows simple command, such as “come here.”
Assigns meaning to words such as “mama, papa,
dada”
58
12-15 mo
* Says one to two words
* Indicates wants by pointing
* Scribbles spontaneously
* Imitates animal sounds
59
15-20
```
• Uses a spoon with little spilling
• Walks up and down steps with help
• Understands two-step commands
• Feeds self
• Carries and hugs doll
• Imitates housework
• Speech: 4–6 words by 15 mo, increases to
≥10 words by 18 mo
• Scribbles vigorously
• Builds tower three cubes tall
```
60
24 mo
* Speaks in sentences of ≥2 words
* Kicks ball on request
* Jumps with both feet
* Uses pronouns
* Is developing handedness
61
24 mo
* Runs
* Copies vertical and horizontal lines
* Has up to a 300-word vocabulary
* Washes and dries hands
* Engages in parallel play
* Puts on simple clothing
62
30 mo
* Walks backward
* Hops on one foot
* Copies circle
63
30 mo
* Gives first and last name
* Uses plurals
* Usually separates easily from parents
64
36 mo
• Holds crayons with fingers
• Nearly all speech intelligible to people not
in daily contact with child
• Three-word sentences
65
36 mo
* Walks down stairs alternating steps
* Rides tricycle
* Copies circles
* Dresses with supervision
66
3-4 yr
• Responds to command to place object in,
on, or under a table
• Knows gender
• Draws circle when one is shown
67
3-4 yr
* Takes off jacket and shoes
* Washes and dries face
* Engages in cooperative play
* Speech includes plurals, personal pronouns, verbs
* Skips
* Asks many questions
68
4-5 yr
• Runs and turns while maintaining balance
• Stands on one foot for at least 10 seconds
• Counts to four
• Draws a person without torso
• Copies (one) by imitation
• Verbalizes activities to do when cold,
hungry, tired
69
4-5 yr
* Buttons clothes
* Dresses self (not including tying shoelaces)
* Can play without adult input for about 30 min
70
5-6 yr
```
• Catches ball
• Knows age
• Knows right from left hand
• Draws person with six to eight parts,
including torso
• Identifies best friend
• Likes teacher
```
71
5-6 yr
• Able to complete simple chores
• Understands concept of 10 items; likely counts
higher by rote
• Has sense of gender
72
6-7 yr
* Copies triangle shape
* Draws person with at least 12 parts
* Prints name
* Reads multiple single-syllable words
73
6-7 yr
* Ties shoelaces
* Counts to ≥30
* Able to differentiate morning from later in day
* Generally plays well with peers
* No significant behavioral problems in school
* Can name intended career
74
FRAGILE X SYNDROME - males
In males: Large testicles (macroorchidism) after the beginning of puberty, large
body habitus, learning and behavioral differences (hyperactivity, developmental
disability common), large forehead and ears, prominent jaw, tendency to avoid
eye contact
75
FRAGILE X SYNDROME - females
In females: Significantly less common with fewer prominent findings, usually with less
severe developmental issues
76
FRAGILE X SYNDROME
Most common known cause of autism in either gender, occurs in all racial and ethnic
groups
77
FRAGILE X SYNDROME
Blood testing available for carrier state (genetic risk for having a child with fragile
X syndrome) or for diagnosis of the condition. Antenatal diagnosis possible
78
XXY MALE
| KLINEFELTER SYNDROME
Only males affected, with developmental issues, most commonly language impairment.
Physical habitus = low testicular volume, hip and breast enlargement.
Blood testing available for carrier state (genetic risk for having a child with Klinefelter syndrome) or for diagnosis of the condition.
Antenatal diagnosis possible.
79
Infant Screening - 1 month
Infant can fixate briefly on the mother’s face. Prefers the human face.
80
Infant Screening - 3 months
Infant will hold the hands close to the face to observe them. Hold a bright
object or a toy in front of the infant. Watch behavior as the infant fixates on the toy for
a few seconds. Avoid using objects/toys that make noises when testing vision.
81
Infant Screening - 6 months
Makes good eye contact. Scans surroundings with 180-degree visual field
82
Infant Screening - 12 months
Makes prolonged eye contact when spoken to. Will actively turn head around 180 degrees to observe people and surroundings for long periods. Recognizes
parents and favorite people from a longer distance
83
Hearing
universal screning while in nursery before discharge
84
Hearing Screening - newboarns
Auditory Brainstem Response (ABR)
Measures the CN VIII by the use of “click” stimuli
Otoacoustic Emissions (OAEs)
Gross hearing test: As a response to loud noise, look for startle response (neonates),
blinking, turning toward sound.
Measures the middle ear mobility only. Less sensitive than the ABR.
85
Mnemonic Device (HEARS) for High-Risk Factors for Hearing Loss:
```
H (hyperbilirubinemia)
E (ear infections that are frequent)
A (Apgar scores low at birth)
R (rubella, cytomegalovirus [CMV], toxoplasmosis infections)
S (seizures)
```
86
Higher incidence of hearing loss
premature infants and infants admitted to NICUs
87
Thyroid-Stimulating Hormone (TSH)
TSH testing is federally mandated. Lack of thyroid hormone results in mental and somatic
growth retardation. Treated by thyroid hormone supplementation.
88
Phenylketonuria (PKU)
PKU testing is federally mandated. Severe mental retardation results if not treated early.
Disorder is an inability to metabolize phenylalanine to tyrosine because of a defect in the
production of the enzyme phenylalanine hydroxylase. Perform test only after infant has
protein feeding (breast milk or formula) for at least 48 hours. Higher risk of false negatives
if done too early (<48 hours). Treated by following special diet (phenylalanine-free diet).
89
Sickle Cell Disease
The required test can detect four types of hemoglobin (hemoglobin F, S, A, and C).
90
Anemia screening
Screening for anemia is done in late
infancy (9–12 months) for full-term, healthy infants. Not screened at birth because
hemoglobin is elevated from maternal RBCs mixed in fetal RBCs.
91
Lead Screening
High-risk children should be screened at age 1 to 2 years (12 and 24 months).
92
Breast Milk
- Give vitamin D drops (400 IU of vitamin D) starting in the first few days of life
- Breast milk or formula contains 20 calories per ounce
- Decreases risk of infections (i.e., otitis media) during the first few weeks of life
93
Colostrum
Sticky and thick yellowish fluid that comes before breast milk. Secreted first few days after
the birth and contains large amounts of maternal antibodies and nutrients.
94
Cow's Milk
- Avoid cow’s milk the first year of life (causes GI bleeding)
- Common cause of iron-deficiency anemia in babies younger than 12 months
95
Meconium
Thick dark-green to black-colored stool that is odorless. Most full-term neonates pass
meconium stool within a few hours of birth.
Failure to pass meconium within 24 hours of
birth is worrisome and may be a sign of intestinal obstruction or cystic fibrosis.
96
Solid foods
start at 4-6 months
start with cereal
97
Introduce foods
one food at a time for 4 to 5 days
98
caput succedaneum
diffused edema of the scalp that crosses the midline.
Caused by intrauterine and vaginal pressure from prolonged or difficult vaginal labor. The scalp
becomes molded and “cone-shaped.” Self-limited and resolves spontaneously.
99
occipitofrontal circumference (OFC).
Use paper tape (cloth tapes stretches)
| and place above the ear.
100
OFC
Head circumference is measured at each wellness visit until the age of 36 months (3 years).
101
newborns
In newborns, chest is about 1 to 2 cm smaller in size than the head circumference
102
Head circumference will increase by 12 cm
during the first 12 months
103
Fastest rate of head growth
during first 3 months of life (2cm/month)
104
Cephalohematoma
Traumatic subperiosteal hemorrhage. Rule out skull fracture (order radiographs of the
skull). Swelling does not cross the midline or suture lines.
105
Birth Weight
Neonates lose up to 7% of body weight but should regain it by 2 weeks of age
106
Neonates double their birth weight by
6 months
107
Neonates triple their birth weight by
12 months
108
Infant weight 0 - 6 months
6 to 8 ounces per week and 1 inch per month
109
infant weight 6 -12 months
3 to 4 ounces per week and 1/2 inch per month
110
FTT
child’s weight and/or length decelerates across two or more major percentiles, rule out FTT
111
FTT
any child who is at the third to fifth percentile is considered to have FTT
112
Causes of FTT
most common causes in primary care are undernutrition and malnutrition. Evaluate the child, including maternal bonding and depression.
113
Length and Height
Length (linear growth) of infants is measured from birth to about 24 months
114
First tooth (primary teeth)
Both the left and right teeth erupt bilaterally at the same time (symmetrical).
115
Teething symptoms
drooling, chewing on objects, irritability, crying, and fever.
6 to 10 months of age: Lower central incisors (lower front teeth)
2½ years of age: Has complete set of primary teeth (20 teeth)
116
First permanent teeth (deciduous teeth)
6 years of age - central incisors and first molars
unit 1 71
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