chapter 25

A 9-month-old has been brought to the clinic for a well-child visit. The mother reports her son was born 6 weeks prematurely. During the data collection, the child's mother reports her son seems to be a few months "behind" what she recalls from her older children. What is the best response by the nurse?

"Delays are normal when a child is premature."

When the nurse discharges a new mom and infant, the nurses notices that the car seat is in the front seat of the car. What is the appropriate response for the nurse to make regarding the car seat?

"Let me go over car seat safety with you, so you can install your car seat properly."

After the nurse provides education to new parents about appropriate sleeping habits for infants, which statement by a parent would indicate to the nurse that teaching needs to reoccur?

"My husband gave the baby a special bear that I will place in the crib."

The father of a 6-week-old infant voices concerns about his son's stooling. He further shares that his son grunts and cries when having a bowel movement. What response by the nurse is mostappropriate?

"What does his stool look like?"

The nurse goes in to check on a new mother to see how breastfeeding is going with her new son. The nurse observes the infant is on the mother's lap with the blanket unwrapped, and the mother is washing his face, and gently stroking the baby. The mother has had trouble breastfeeding the last few times. What is the appropriate response from the nurse?

"You are doing a wonderful job attempting to wake the baby."

A parent asks the nurse if the 2-month-old infant can have bananas yet. The nurse would respond and educate the parent on the nutrition stages of infants by which response?

"You can try bananas 2 or 3 months from now."

A parent takes the 4-month-old infant to the health care provider. The parent asks what type of baby cereal to provide now that the infant is starting solid foods. How should the nurse respond?

"You should buy rice cereal."

A mother asks the nurse where the microwave is so that she can warm up breast milk to feed her baby. What is the best response by the nurse?

"You should warm the milk under warm water instead."

The nurse is assessing the 10-month-old infant. The nurse notes the anterior fontanel (fontanelle) has closed. What initial action by the nurse is indicated?

Document the findings as normal.

The nurse is completing an infant history on a 5-month-old and documents the following symptoms. Which will the nurse attribute to teething? Select all that apply.

Drooling and biting Increased sucking on hands Irritability and awakening from sleep Refusing to eat

The nurse is promoting a healthy diet to the mother of a 6-month-old. What action would have the most effect on the infant's neurologic development?

Promoting continuation of breastfeeding

A nurse is educating a client being discharged with her newborn baby. What is the highest priority item that must be included in the teaching plan?

Restrain the baby in a car seat.

A nurse places a toy car in front of a 6-month-old girl. She swats at it, and the car flies across the examination table and lands on the floor. She squeals with surprise and delight. When the nurse puts the toy car in front of her again, she immediately swats it again and laughs as it rolls across the table and falls to the floor again. What has the girl demonstrated?

Secondary circular reaction

Which milestone would the nurse expect an infant to accomplish by 8 months of age?

Sitting without support

The nurse is assessing the sleeping practices of the parents of a 4-month-old girl who wakes repeatedly during the night. Which parent comment might reveal a cause for the night waking?

They put her to bed when she falls asleep.

The nurse is performing an assessment on a 8-month-old infant. The infant's medical history notes that he was born at 32 weeks' gestation. The infant is progressing normally. At what adjusted age should the nurse expect the infant's developmental accomplishments?

The infant will most likely present with developmental skills consistent with a 6-month-old infant.

The mother of a 1-month-old infant voices concern about her baby's respirations. She states they are rapid and irregular. Which information should the nurse provide?

The respirations of a 1-month-old infant are normally irregular and periodically pause.

The nurse is assessing the oral cavity of a 6-month-old child. When palpating the location in which the first primary teeth erupt, which location is being assessed?

lower central gumline

A mother of a 9-month-old 18-pound (8.2 kg) infant asks the nurse about choosing the best car seat. What should the nurse recommend?

a rear-facing 5-point harness restraint

The parent of an infant asks the nurse when to begin brushing the infant's teeth. What would be the nurse's best response?

as soon as the first tooth erupts

The nurse is educating the mother of a 6-month-old boy about the symptoms for teething. Which symptom would the nurse identify?

increased biting and sucking

The nurse is teaching the parents of a 6-month-old infant about proper dental care. Which action will the nurse indicate as most likely to cause dental caries in this infant?

putting the infant to bed with a bottle of milk or juice

During the first visit to the pediatrician's practice the nurse is performing an admission interview and assessment of a 4-week-old infant. The mother states, "I am sure my baby girl knows my smell because she is much more settled in my arms rather than my mother's arms when she is upset." What is an appropriate response by the nurse?

"You may be right, since infants can sense their mother's smell as early as 7 days old."

A nurse is preparing to administer vaccines to a 4-month-old infant. Which vaccines will the nurse administer? Select all that apply.

Haemophilus B inactivated poliomyelitis diphtheria, tetanus, and pertussis pneumococcal