Infancy: trust, rapid change and aspiration risk
The first year is the fastest period of change and therefore the densest source of milestone questions. Birth weight doubles by about six months and triples by twelve. The posterior fontanel closes by two months and the anterior by twelve to eighteen months, and a bulging fontanel signals raised intracranial pressure while a sunken one signals dehydration. Head control comes first, then rolling, then sitting, then crawling, then standing and walking — always proximal to distal, head to toe.
Erikson's stage is trust versus mistrust, established by consistent, prompt response to the infant's needs. That is why the correct nursing answers in this age group emphasise holding, comforting, keeping the parent present, and maintaining routines. Separation anxiety appears around six to eight months, so parental presence during procedures is not merely kind, it is developmentally indicated.
Safety teaching centres on aspiration and suffocation. Infants are placed supine to sleep on a firm surface with no pillows, bumpers or loose blankets. Small objects, latex balloons, grapes, hot dogs, popcorn and nuts are hazards. Car seats are rear-facing in the back seat. Water temperature is checked, and an infant is never left unattended on a raised surface once rolling begins. Solid foods begin around six months, introduced one at a time for several days to identify allergy, and honey is avoided in the first year because of botulism risk.
- •2 months — social smile; 4 months — rolls front to back
- •6 months — sits with support, transfers objects, doubles birth weight
- •9 months — crawls, pincer grasp developing, stranger anxiety
- •12 months — walks with or without help, triples birth weight, one to three words
- •Play is solitary; safe toys are large, soft and unbreakable
Toddler and preschool: autonomy, initiative and magical thinking
Toddlers between one and three years are working on autonomy versus shame and doubt. Their signature behaviours are negativism, saying no to everything, and ritualism, insisting that routines be performed identically. The nursing answer is almost always to allow control within safe limits: offer two acceptable choices rather than open-ended questions, maintain home routines during hospitalisation, and expect regression under stress. Temper tantrums are managed by ignoring the behaviour while ensuring safety.
Toddler play is parallel — playing alongside rather than with other children — and toys should support gross motor development and imitation: push-pull toys, large blocks, thick crayons, board books. Toilet training readiness appears between 18 and 24 months and depends on physiological readiness such as staying dry for two hours and being able to walk to the toilet, plus the ability to communicate the need. Safety shifts to falls, poisoning, drowning and burns as mobility increases.
Preschoolers between three and five are in initiative versus guilt. They are curious, imaginative, and prone to magical thinking, which means they may believe illness is a punishment for something they did. That belief drives some of the most commonly tested interventions: give simple, honest, concrete explanations, reassure the child that they did not cause the illness, allow therapeutic play with medical equipment, and use dolls or puppets to prepare for procedures. Fear of body mutilation is intense, so bandages over injection sites matter more than the injection itself.
Preschool play is associative — children play together at a shared activity without formal organisation. Dress-up, drawing, tricycles and simple games support this stage. Language expands rapidly, and by five years most children speak in full sentences and can follow a three-step command.
| Age group | Erikson stage | Play | Key nursing approach |
|---|---|---|---|
| Infant (0–1) | Trust vs mistrust | Solitary | Consistent comfort, keep parent present |
| Toddler (1–3) | Autonomy vs shame | Parallel | Offer limited choices, keep routines |
| Preschool (3–5) | Initiative vs guilt | Associative | Simple honest words, therapeutic play |
| School age (6–12) | Industry vs inferiority | Cooperative | Explain how things work, allow participation |
| Adolescent (13–18) | Identity vs role confusion | Peer group | Privacy, confidentiality, peer contact |
School age and adolescence: competence, identity and risk
School-age children between six and twelve are in industry versus inferiority. They want to accomplish things, to be competent, and to be treated as capable. Nursing interventions therefore centre on giving factual explanations of how procedures work, involving the child in their own care, allowing choices about the sequence of care, maintaining schoolwork and peer contact, and praising accomplishment. Their play is cooperative and rule-governed, which is why board games, team sports, collections and craft projects work well during hospitalisation.
Fears shift from body mutilation to loss of control and to death. Modesty becomes important, so privacy during examination is a genuine intervention rather than a courtesy. Concrete operational thinking means these children can understand cause and effect if you explain it plainly, but abstract concepts still require simple analogies.
Adolescents between thirteen and eighteen face identity versus role confusion. Peer relationships dominate, body image is fragile, and the sense of personal invulnerability drives risk-taking. Nursing answers emphasise privacy and confidentiality within legal limits, interviewing the adolescent without the parent present for part of the visit, involving them directly in decisions, permitting personal clothing and belongings, and encouraging peer visits. Confronting an adolescent about behaviour in front of parents or peers is consistently the wrong option.
Health teaching for adolescents covers sexual health, substance use, mental health screening including depression and suicidal ideation, safe driving, helmet use, and nutrition, particularly calcium and iron during the growth spurt. Eating disorders and scoliosis screening also cluster in this age group and appear regularly on the exam.
- •School age — explain, involve, protect modesty, maintain school and friends
- •Adolescent — privacy, confidentiality, peer contact, involve in decisions
- •Screen adolescents for depression, substance use and risk behaviour
- •Growth spurt increases calcium, iron and calorie needs
Pain, communication and how the questions are written
Pain assessment tools are age-matched and appear constantly. FLACC, a behavioural observation scale, is used for infants and preverbal children. The FACES scale suits children from about three years. A numeric zero to ten scale is appropriate from around eight years and for adolescents. Choosing a tool the child cannot developmentally use is a standard distractor.
Communication guidance follows the same age logic. Speak to infants softly and keep the caregiver visible. Approach toddlers slowly, examine from toe to head to build trust, and allow them to hold a comfort object. Use play and simple words with preschoolers. Give school-age children real information and a role. Talk to adolescents directly, not through their parents.
Most development items are written in one of three ways: which behaviour is expected at this age, which toy or activity is appropriate, and which teaching point the parent needs. Studying milestones alongside play and safety for each age answers all three formats at once. Our child health question sets and mock exams present development items in exactly these formats with full rationales.