Maternal/OB: Peds Mastery infant Chapter 16
The nurse is assessing the motor responses of an 8-month-old infant. Which finding would concern the nurse? 1. Prehension 2. Grasp reflex 3. Pincer grasp 4. Parachute reflex
Grasp reflex. --This reflex should disappear at about 3 months of age.
A 12-month-old infant has a respiratory rate of 35 breaths/min and a pulse rate of 120 beats/min. The infant's weight is three times the birth weight and height is 29 inches. Which condition would the nurse document in the electronic medical record regarding this child's status? 1. Obesity 2. Bradycardia 3. Healthy growth 4. Respiratory depression
Healthy growth. --Normal respiratory rate for a 12 month old: 20 - 40 breaths/min. --Normal pulse rate for a 12 month old: 100 - 140 beats/min.
Which food might cause botulism if given to an infant? 1. Sugar 2. Honey 3. Egg yolk 4. Green beans
Honey. --Honey shouldn't be given to children younger than 2 years.
The nurse is collecting the data on infants of different age groups. Which infant does the nurse identify as having impaired growth and development? 1. Infant A 2. Infant B 3. Infant C 4. Infant D
Infant C. --An infant at 12 months old should be able to walk three steps without support --They should also be able to hold objects and place them in a pan.
Which intervention will the nurse discuss with the mother of a 1-month-old infant? 1. Breast-feeding the infant every hour. 2. Placing the infant in the supine position 3. Placing a pillow under the infant's head. 4. Avoiding exposure of the infant to sunlight
Placing the infant in the supine position. --To provide support to the infant's back.
Which instruction would the nurse provide to the mother of a 3-month-old infant regarding nutrition? 1. "Feed the infant breast milk or formula." 2. "Feed the infant foods that contain gluten." 3. "Provide the infant finger foods like toast." 4. "Feed the infant chopped and mashed foods."
"Feed the infant breast milk or formula."
Which statement by the parent of a 14-month-old child would cause the nurse to be concerned about impaired growth and development in the child? 1. "I am feeding my baby a low-fat diet." 2. "I am feeding my baby fiber-rich food." 3. "I am giving whole cow's milk to my child." 4. "I am giving mango and apple juice to my baby."
"I am feeding my baby a low-fat diet." --This shouldn't occur before 2 years of age due to the fatty acids present in food are important for brain development.
The nurse has provided parental teaching about the use of different formula preparations. Which parent statement would concern the nurse? 1. "I do not have to refrigerate ready-to-feed formula." 2. "Powdered formula is the least expensive formula." 3. "I will make sure I dilute the concentrated formula." 4. "I can prepare a day's feedings if I use concentrated formula."
"I do not have to refrigerate ready-to-feed formula." --Refrigeration is needed after it is opened.
The nurse is teaching a parent about the introduction of solid foods to the infant. Which information would the nurse include in the instructions? 1. "Introduce the foods before a milk feeding." 2. "Offer only half a jar when introducing new foods." 3. "Begin with mixing the cereal in the bottle with milk." 4. "Place a small amount of food on the tip of the tongue."
"Introduce the foods before a milk feeding." --This will encourage the infant to try the new food.
Which parent statement regarding a 6-month-old infant would indicate to the nurse the development of prehension is appropriate? 1. "My baby can tell when someone has a happy face." 2. "My baby can transfer toys from one hand to the other." 3. "My baby has begun showing signs of separation anxiety." 4. "My baby can grasp and hold things in the palm of the hand."
"My baby can grasp and hold things in the palm of the hand."
A mother verbalizes concern that her second-born son is reaching milestones but not as quickly as her first-born child. Which response by the nurse is appropriate? 1. "I will let the physician know right away." 2. "A psychology consult should be ordered." 3. "Norms can vary greatly for the individual child." 4. "Milestones should be reached consistently by each child."
"Norms can vary greatly for the individual child."
Which suggestion would the nurse give to the parent of 6-month-old infant who states, "I want to introduce solid foods in my baby's diet"? 1. "Offer single-ingredient foods." 2. "Offer multiple-ingredient foods." 3. "Offer new foods along with honey." 4. "Offer large amounts of food at one time."
"Offer single-ingredient foods." --To determine possible allergies toward particular foods. --To determine tolerance in the infant, the parent should offer the new food for 4-7 days and should check for any signs of food allergy.
Which conditions in the mother are contraindications to breast-feeding? Select all that apply. 1. Galactosemia 2. Illicit drug use 3. Phenylketonuria 4. Chemotherapy treatment 5. Untreated pulmonary tuberculosis
2, 4, 5 -Illicit drug use -Chemotherapy treatment -Untreated pulmonary tuberculosis --Galactosemia & Phenylketonuria: Both ailments in the infant that doesn't allow them to ingest breast milk.
The nurse is teaching home safety to the parent of an 11-month-old infant. Which suggestion would the nurse provide to the parent to ensure the safety of this infant? Select all that apply. 1. Cover the electrical outlets. 2. Provide teething toys to the infant. 3. Provide push-pull toys to the infant. 4. Keep any the medication out of reach 5. Intermittently place the infant in a sitting position.
1, 4, 5 -Cover the electrical outlets. -Keep any medication out of reach. -Intermittently place the infant in a sitting position.
The posterior fontanelle in a 2-month-old infant is closed. Which other characteristic of proper development will the nurse observe? Select all that apply. 1. The infant weighs 2.6 kg. 2. The infant has a wobbly head. 3. The infant has active leg movements. 4. The infant holds a toy for a short time. 5. The infant follows moving lights with its eyes
3, 4, 5 -The infant has active leg movements. -The infant holds a toy for a short time. -The infant follows moving lights with its eyes.
A neonate's birth weight is 3 kg. What is the expected weight of the neonate at the age of 6 months? Record your answer using a whole number. Answer: ____________ kg
6 kg (13.2 lbs). --Weight of infant usually doubles by the age of 6 months &_ triples by the age of 1 year.
The nurse is discussing food choices for an 11-month-old infant with the child's parents. Which food would the nurse include in the recommendation? 1 .Fish 2. Egg white 3. Low-fat milk 4. Apple juice
Apple juice. --Fruit juices can be given to the infant from 5-6 months of age.
While caring for an infant, the nurse notices skin breakdown and rashes on the diaper area. Which practice would the nurse instruct he parents to adopt? 1. Avoiding the use of diapers 2. Applying baby powder to the affected area 3. Washing the affected area with soap and water 4. Applying protective ointment to the affected area
Applying protective ointment to the affected area. --Such as Desitin. --Airing out the diaper area also helps the infant's skin heal faster.
Which organ's functioning is improved by the addition of docosahexaenoic acid (DHA) to commercial formulas? 1. Liver 2. Brain 3. Heart 4. Kidney
Brain. --Docosahexaenoic acid (DHA) is a: Long chain polyunsaturated fatty acid (LC-PUFA). --> Omega-3 fatty acid.
The nurse observes the parent holding an infant face down, close to their body, and applying light pressure on the abdomen while providing a gentle rocking motion. Which condition is present in the infant based on these observations? 1. Colic 2. Insomnia 3. Poor feeding 4. Regurgitation
Colic.
The nurse is caring for a 3-month-old infant with gastroesophageal reflux disease (GERD). Which type of feeding is beneficial for the infant? 1. Phenix 2. Lofenalac 3. Enfamil A.R. 4. Gluten-based formula
Enfamil A.R. (Rice starch containing). --It provides the required amount of calories and prevents loose stools.
The nurse is caring for a 3-month-old infant who has phenylketonuria (PKU). Which type of formula would the nurse expect the health care provider to recommend? 1. Lofenalac 2. ProSobee 3. Soy-based 4. Enfamil A.R
Lofenalac. --It does not contain phenylalanine & prevents increases in the levels of phenylalanine.
Protective arm extension that occurs when an infant is suddenly thrust downward when prone is known as which reflex? 1. Blink 2. Startle 3. Babinski 4. Parachute
Parachute. --Appears by age 7-9 months.
Which reflex is the nurse observing when an 8-month-old infant extends the arms when suddenly thrust downward into the prone position? 1. Grasp 2. Rooting 3. Parachute 4. Tonic neck
Parachute. --The infant should exhibit the parachute reflex by 7-9 months of age. --Checking the reflex helps identify motor development in the infant. **Grasp reflex: The infant is able to hold the finger of the nurse upon touching the palms (disappears by 3 months of age). **Rooting reflex: The infant automatically turns the head in the anticipation of food (disappears by 4 months of age). **Tonic neck reflex: Observed when the infant is placed in the supine position (disappears by 4 months of age).
Which reflex is the nurse observing when an 8-month-old infant extends the arms when suddenly thrust downward into the prone position ? 1. Grasp 2. Rooting 3. Parachute 4. Tonic neck
Parachute. --This should be exhibited by 7 - 9 months of age. --Checking for this reflex helps identify motor development in the infant.
Which reflex is the nurse observing in an infant who picks up food with the finger and thumb and places it in the mouth? 1. Rooting 2. Extrusion 3. Parachute 4. Pincer grasp
Pincer grasp. **Extrusion reflex: The infant prevents the intake of inappropriate food by pushing it out of the mouth.
The nurse is caring for an 8-month-old infant who has galactosemia and is allergic to cow's milk. Which feeding would the nurse provide to the infant? 1. Whole milk 2. Low-fat milk 3. Soy formula 4. ProSobee formula
ProSobee formula. --Infants with galactosemia may have a carb deficiency. --ProSobee: A lactose-free corn syrup with high amounts of carbs.
The nurse observes that a 2-month-old infant has established the extrusion reflex. Which actions of the infant enabled the nurse to reach this conclusion? 1. Pushing the food out of the mouth 2. Picking up food and placing it in the mouth 3. Presenting a protective extension of the arms 4. Holding objects between the fingers and thumb
Pushing the food out of the mouth. --The extrusion reflex appears in the infant at birth & disappears after 3 or 4 months. --It refers to the protrusion of the tongue to push inappropriate food out of the mouth.
A patient on the postpartum unit tells the nurse she would like a different formula for her baby. Which action would the nurse take? 1. Obtain a different formula from the nursery. 2. Request a consultation with the health care provider. 3. Tell the patient to change the formula after hospital discharge. 4. Tell the patient the formula provided is the best choice and should not be changed.
Request a consultation with the health care provider. --Feeding the wrong formula is considered a medication error. --PCP can consult with the patient and provide the documentation needed.
Which milestone of physical development is expected in an 8-month-old infant? 1. Develops tears 2. Sits steadily alone 3. Cruises on furniture 4. Shows preference for one hand
Sits steadily alone. --Also, using the index finger and thumb as pincers, poking at objects, and enjoying dropping an article into a cup and emptying it.
A 10-month-old infant is observed to have impaired prehension. Which finding in the infant enabled the nurse to reach this conclusion? 1. The infant drops one toy at a time. 2. The infant cannot build a tower with two cubes. 3. The infant uses his or her fingers to explore things. 4. The infant cannot hold objects with the thumb and index finger.
The infant cannot hold objects with the thumb and index finger. --An infant should be able to do this by age 8 months.
Which explanation would the nurse provide to the parents of a 3-month-old infant when instructing them to avoid feeding the infant solid foods? 1. The infant has low fluid requirements. 2. The infant has high serum iron levels. 3. The infant has a high basal metabolic rate. 4. The infant does not produce amylase and lipase
The infant does not produce amylase and lipase. --Digestive enzymes such as amylase and lipase do not take place until an infant is 4 - 6 months old.
Which explanation would the nurse provide to parents during a well-baby visit regarding why the height, weight, and head circumference of the infant is measured? 1. To determine the infant's satiety 2. To evaluate the infant's feeding behavior 3. To evaluate the adequacy of the infant's diet 4. To determine the infant's neurological development
To evaluate the adequacy of the infant's diet. --An infant with adequate nutrition gains 4 - 7 ounces per week during the first 6 months of life.
Which assessment finding would the nurse be most concerned about in a 12-month-old infant during a well-child checkup? 1. Unable to walk 10 to 15 steps 2. Doesn't drink from a sippy cup 3. Unable to pull up to a sitting position 4. Provides frequent objections to foods
Unable to pull up to a sitting position. --This may be a sign of delays.
Which assessment finding would the nurse be most concerned about in a 12-month-old infant during a well-child checkup? 1. Unable to walk 10 to 15 steps 2. Doesn't drink from a sippy cup 3. Unable to pull up to a sitting position 4. Provides frequent objections to foods
Unable to pull up to a sitting position. --This may indicate delays.
Which suggestion would the nurse give to the parent of 6-month-old infant who states, "I want to introduce solid foods in my baby's diet"? 1. "Offer single-ingredient foods." 2. "Offer multiple-ingredient foods." 3. "Offer new foods along with honey." 4. "Offer large amounts of food at one time."
"Offer single-ingredient foods." --To help determine possible allergies toward particular foods. --The parent should offer the new food for 4 - 7 days and check for signs of food allergy.
The nurse is teaching the parents of a 4-month-old infant about feeding solid food. Which statement by the parent needs correction? 1. "I should avoid giving mixed vegetables." 2. "I will offer only 1 teaspoon of food initially." 3. "I plan to mix cereal with whole cow's milk." 4. "I can introduce only one new food per week."
"I plan to mix cereal with whole cow's milk." --An infant younger than 1 cannot digest whole cow's milk, leading to GI disorders. --Cereal should be diluted with formula or water.
The nurse is teaching infant care to the parent of a 4-month-old. Which response by the parent indicates the need for further teaching? 1. "I will change wet diapers as soon as possible." 2. "I plan to take the baby out in the stroller every day." 3. "I should keep the baby is in the crib most of the time." 4. "I can use a pacifier to soothe the baby when she cries."
"I should keep the baby is in the crib most of the time." --This will not expose her to various learning experiences, and may result in the infant being shy and withdrawn as a result.
The nurse is teaching the signs of satiety to the parent of a 5-month-old infant. Which statement by the parent needs correction? 1. "I should stop feeding if my child plays with the nipples." 2. "I should stop feeding if my child gets distracted while feeding." 3. "I should stop feeding if my child shakes his head to indicate 'no.'" 4. "I should stop feeding if my child withdraws his head from the nipple."
"I should stop feeding if my child shakes his head to indicate 'no.'" --This is more common when the infant is between 6-9 months old.
A parent tells the nurse that she would like to supplement with formula after breastfeeding. Which response would the nurse provide the parent? 1. "The combination may contribute to colic." 2. "The baby may experience vomiting and diarrhea." 3. "The nutrients in the breast milk may not get absorbed." 4. "The passive immunity the baby receives from the breast milk is decreased."
"The nutrients in the breast milk may not get absorbed."
A mother tells the nurse that her infant has begun clutching the mother's legs when leaving the infant at the day care center. Which statement would the nurse provide the parent? 1. "This is an expected reaction for a 6-month-old infant." 2. "This is an expected reaction for a 9-month-old infant." 3. "This is an expected reaction for a 10-month-old infant." 4. "This is an expected reaction for a 12-month-old infant."
"This is an expected reaction for a 12-month-old infant." --This is the goal of corrected partnership.
The nurse is teaching techniques to help parents cope with an infant who cries during feeding and diaper-changing. Which statement by the parents needs correction? 1. "I can offer the baby a pacifier to suck." 2. "We always sing while sitting with the baby." 3. "We sometimes talk to the baby in a soft voice." 4. "We will always shield the baby's eyes from bright lights."
"We always sing while sitting with the baby." --The nurse would encourage the parents sit silently with the infant without talking or singing. (To minimize environmental stimuli & help calm the infant).
The nurse is teaching the parents of an 8-month-old infant about car safety. Which instruction will the nurse provide to prevent injury to the infant? 1. "You should not place your baby in a rear-facing seat." 2. "You should not firmly anchor your baby's seat to the car seat." 3. "You should not leave your sleeping baby in the car seat for a long time." 4. "You should not place your baby's seat in the middle of the car's rear seat."
"You should not leave your sleeping baby in the car seat for a long time." --The infant may flex his or her neck downwards to rest the chin on the chest, this may cause oxygen desaturation and increase the risk for hypoxia.
The nurse is teaching the parents of an 8-month-old infant about car safety. Which instruction will the nurse provide to prevent injury to the infant? 1. "You should not place your baby in a rear-facing seat." 2. "You should not firmly anchor your baby's seat to the car seat." 3. "You should not leave your sleeping baby in the car seat for a long time." 4. "You should not place your baby's seat in the middle of the car's rear seat."
"You should not leave your sleeping baby in the car seat for a long time." --The infant may flex his or her neck downwards to rest the chin on the chest, this may cause oxygen desaturation and increase the risk of hypoxia. P. 405
Which outcome results from holding an infant in a comfortable position while breast-feeding, covering the infant in warm clothes, and providing sufficient time to suck? Select all that apply. 1. The infant is comfortable. 2. Forced feeding is minimized. 3. The infant's grasp reflex is induced. 4. The infant associates food with love. 5. The infant's sucking reflex is induced.
1, 2, 4 -The infant is comfortable. -Forced feeding is minimized -The infant associates food with love.
The nurse is assessing the reflexes of a 9-month-old infant. Which reflexes would concern the nurse if they are still present? Select all that apply. 1. Moro 2. Pincer 3. Rooting 4. Extrusion 5. Tonic neck
1, 3, 4, 5 -Moro -Rooting -Extrusion -Tonic neck --These reflexes disappear around 4 months of age. **Pincer grasp: Begins to develop around 8 months of age.
Which formula will be beneficial for infants with high protein sensitivity? Select all that apply. 1. Phenix 2. EleCare 3. Neocate 4. Lofenalac 5. Similac Isomil
2 & 3 -EleCare (Hydrolyzed formula) -Neocate (Amino acid-based elemental formula) **Phenix & Lofenalac: Given to infants with phenylketonuria. **Similac Isomil: Lactose-free formula given to infants with galactosemia.
Which intervention will the nurse include in the plan of care for a lethargic infant? Select all that apply. 1. Provide nonnutritive sucking. 2. Talk to the infant in a calm voice. 3. Cradle the infant firmly in the lap. 4. Place the infant in a dimly lit room. 5. Sit the infant in an upright position.
2, 4, 5 -Talk to the infant in a calm voice. -Place the infant in a dimly lit room. -Sit the infant in an upright position.
Which techniques can be used to soothe an irritable infant? Select all that apply. 1. Singing 2. Vigorous rocking 3. Nonnutritive sucking 4. Changing position frequently 5. Swaddling snugly with the hands near the face
3 & 5 -Nonnutritive sucking -Swaddling snugly with the hands near the face --Shield the infant's eyes from bright light --Sitting quietly without talking or singing --Eliminating noise from radio, television, and computer. --Talking in a soft voice. --Changing the infant's position slowly --Stopping the interaction and reducing environmental stimuli if the infant runs away, squirms, grimaces, or puts the hands in front of the face. --Rocking the infant slowly and gently. --Avoiding sudden movements. --Cradling the infant firmly in the lap during feeding --Remaining still during sucking efforts.
While caring for a 12-month-old child, the nurse observes that the child has reduced sensorimotor coordination. Which action by the parents will be beneficial for this child? 1. Rocking the child frequently 2. Playing with the child on a swing 3. Introducing push-pull toys to the child 4. Playing peek-a-boo games with the child
Introducing push-pull toys to the child. --This helps develop locomotion in the child due to reduced sensorimotor coordination. P. 405
Which intervention would the nurse teach to the parents of a 7-month-old infant to reduce the risk for sudden infant death syndrome (SIDS)? 1. Feeding the infant in small quantities 2. Tapping the infant's back after feeding 3. Placing the infant on his back while sleeping 4. Placing the infant on his abdomen after feeding
Placing the infant on his back while sleeping.
The nurse is teaching a parent about the behavior a 4-month-old infant should display when hungry. Which information will the nurse include in the teaching? 1. "Your baby's body will be tense." 2. "Your baby will try to reach for the bottle." 3. "Your baby's hands will be placed in the mouth." 4. "Your baby will react to you preparing the bottle."
"Your baby's hands will be placed in the mouth." **A tense body is a sign of hunger for an infant from birth to 3 months. **An infant aged 6 - 9 months will reach for the bottle and react to the preparation of the bottle.
The nurse is preparing to teach a parent about the expected changes in the sleep pattern of a 4-month-old infant. Which statement would the nurse include in the teaching? 1. "Your infant may sleep from feeding to feeding." 2. "Your infant will likely sleep through ordinary household noises." 3. "You can expect your infant to take two or three naps per day." 4. "You can expect your infant to begin sleeping later in the morning."
"Your infant will likely sleep through ordinary household noises."
A parent asks how she will know her breastfed 4-month-old infant is getting adequate nutrition. Which information would the nurse include in teaching? 1. "Your infant should be eating every 3 to 4 hours." 2. "Your infant should gain about 9 ounces per week." 3. "Your infant will sleep for several hours after eating." 4. "Your infant should have at least three wet diapers per day."
"Your infant will sleep for several hours after eating."
A 2-month-old infant is irritable and cries frequently, according to the parents. Upon assessment, the nurse determines the infant is healthy and is feeding effectively. Which intervention would the nurse teach to help parents in this situation? Select all that apply. 1. Massaging the infant's abdomen 2. Placing the infant in a dimly lit room 3. Placing the infant in the supine position 4. Holding the infant in the colic carry position 5. Placing the infant in the upright sitting position
1 & 4 -Massaging the infant's abdomen. -Holding the infant in the colic carry position.
The nurse is teaching a parent about buying, storing, and serving baby food. Which statement by the parent indicates effective learning? Select all that apply. 1. "I will check for the expiration date on the jar." 2. "I can return leftover food to the jar to avoid waste." 3. "I should listen for the 'pop' sound while opening the jar." 4. "I should refrigerate the unused portions in the original jar." 5. "I always check safety seals and the expiration date before purchasing."
1, 3, 4, 5 -"I will check for the expiration date on the jar." -"I should listen for the 'pop' sound while opening the jar." -"I should refrigerate the unused portions in the original jar." -"I always check safety seals and the expiration date before purchasing."
The mother of a 4-month-old infant raises concern about the infant's breast-feeding habits. The nurse instructs the mother not to feed the infant forcefully. Which statements by the mother would have led to this instruction? Select all that apply. 1. "My baby ejects the nipples while breast-feeding." 2. "My baby is protruding the tongue when I try to feed her." 3. "My baby is tossing her head back while breast-feeding." 4. "My baby changes posture suddenly while breast-feeding." 5. "My baby suddenly stops sucking and starts playing with the nipple."
1, 3, 5 -"My baby ejects the nipples while breast-feeding." -"My baby is tossing her head back while breast-feeding." -"My baby suddenly stops sucking and starts playing with the nipple." --The mother should stop feeding when the infant exhibits these behaviors.
Which vaccines should an infant receive at the age of 4 months? Select all that apply. 1. Injectable polio vaccine (IPV) 2. Second hepatitis B virus (HBV) 3. Haemophilus influenza type B (Hib) 4. Second Haemophilus influenza type B (Hib) 5. Second diphtheria tetanus and pertussis (DTaP)
1, 4, 5 -Injectable polio vaccine (IPV) -Second Haemophilus influenza type B (Hib) -Second diphtheria tetanus and pertussis (DTaP) --These are to boost the effect of the same vaccines received by the infant at the age of 2 months.
Which amount of liquid intake per day is recommended for a 6-month-old infant according to the National Research Council? 1. 90 to 100 mL/kg/day 2. 130 to 155 mL/kg/day 3. 120 to 135 mL/kg/day 4. 140 to 160 mL/kg/day
130 to 155 mL/kg/day. --6-year-old: 90-100 mL/kg/day --1-year-old: 120-135 mL/kg/day --3-month-old: 140-160 mL/kg/day
