newborns and infants
A mother brings her child to the clinic for a 12-month well visit. The child weighed 6 pounds 2 ounces and was 21 inches long at birth. What finding indicates that the child needs further assessment? a. Height of 30 inches b. Weight of 16 pounds c. The infant is not yet potty-trained. d. The infant is not yet walking up stairs.
ANS B Size increases rapidly during the first year of life. Birth weight doubles in approximately 5 months and triples by 12 months. This infant should weigh at least 18 pounds by this calculation. This child needs further assessment. Height increases an average of 1 inch during each of the first 6 months and about 1/2 inch each month until 12 months: 21 + 6 + 3 = 30 (30 inches is the predicted height). Patterns of body function are just now starting to stabilize. It is quite normal for a 12-month-old child to not be potty-trained or walking up stairs yet. These milestones usually occur in the toddler period of development (12 to 36 months). In the toddler stage, rapid development of motor skills allows the child to participate in self-care activities such as feeding, dressing, and toileting. Soon the child begins to navigate stairs, using a rail or the wall to maintain balance.
The nurse is providing information to parents of infants regarding home safety. Which information will the nurse present that is specific to this age group? Select any that apply. 1. Crib safety standards 2. Avoiding taking the infant out in public 3. Hazards of immunizations 4. Diaper rash prevention 5. Signs and symptoms of illness to report
ANS: 1, 4, 5 1. This is correct. Infants spend most of their time in cribs, which must be safe— no bumper pads, slats no more than 2-3/8 inches apart. 4. This is correct. Prevention is the best treatment for diaper rash, which can cause pain and possible infections because of a loss of skin integrity. 5. This is correct. Parents need to understand the importance of calling a physician if the infant has a fever, refuses to eat, has vomiting and/or diarrhea, is more fussy or quieter than usual or looks jaundiced, and if they are worried or have questions about the infant's growth or development. 2. This is incorrect. Keep anyone with a cough, cold, or infectious disease away from the infant; otherwise, it is acceptable to take the infant out in public. 3. This is incorrect. Immunizations need to be administered at specific times beginning as an infant.
The nurse in a pediatric clinic is frequently required to administer medications to infants. Which approach will the nurse take when administering an immunization injection? 1. Use a 1-inch needle with a maximum of 1.5 mL of fluid. 2. Keep the infant on the caregiver's lap and use distraction. 3. Explain the medication and the purpose in simple terms to the infant. 4. Immediately comfort the infant with cuddling and patting.
ANS: 2 2 This is correct. The nurse should approach the infant slowly and at eye level. Handle the infant gently, keep the infant on the caregiver's lap, and use distraction in order to decrease anxiety. 1 This is incorrect. For a small infant, a 5/8-inch needle with a maximum of 0.5 mL of fluid is used. For larger infants, a 1-inch needle with a maximum of 1.0 mL of fluid is administered into the vastus lateralis. For adolescents, the nurse should use a 1- to 1.5-inch needle (22- to 27-gauge) and up to 3 mL of fluid maximum. 3 This is incorrect. The nurse may explain the medication and the purpose to the caregiver but not to the infant. 4 This is incorrect. The parent should be encouraged to comfort the infant with cuddling and patting. Additional interactions by the nurse at this time is likely to cause more stress.
During a parenting class, a father states, "My wife cannot hold the baby without singing, even in public. It's kind of embarrassing for me." Which opinion does the nurse share with the group after researching the topic? 1. Caregivers sometimes sing for their own attention and benefit. 2. The father can walk away from public places if the mother sings. 3. The mother needs to find another way of comforting her baby. 4. Singing of lullabies by caregivers has a calming effect on infants.
ANS: 4 4 This is correct. Research indicates music has been shown to stimulate neurological growth and development, to calm, and to improve sleeping patterns in infants. This is an appropriate research finding to present to parents. 1 This is incorrect. Research indicates the singing of lullabies by caregivers has a calming effect on infants, even if caregivers do not know the words to the songs. There is no mention that the parent is seeking attention or personal benefit. 2 This is incorrect. The father can walk away from the mother who sings to her baby in public; however, the action may create tension in the relationship. The nurse can suggest quiet humming or quiet recorded music when in public. 3 This is incorrect. Music is an effective way to calm an infant. Researchers and studies have shown that music therapy has the potential to improve cognitive development. Playing soft and soothing music improves psychological well-being. Quiet recorded music will still provide the positive benefits to the infant.
After comparing appropriate play activities for infants and preschool children, the nurse should appropriately offer which of the following activities to an infant? a. Set of cards to organize and separate into groups b. Set of plastic stacking rings c. Paperback book d. Set of sock puppets with movable eyes
ANS: B Play becomes manipulative as the child learns control of the hands. Adults facilitate infant learning by planning activities that promote the development of milestones, and by providing toys that are safe for the infant to explore with the mouth and manipulate with the hands, such as rattles, wooden blocks, plastic stacking rings, squeezable stuffed animals, and busy boxes. Preschoolers demonstrate their ability to think more complexly by classifying objects according to size or color, making the cards more appropriate for them. Neither group is ready for paperback books. The sock puppet with movable eyes could create a choking hazard if one of the eyes comes off.
The nurse who is teaching a parent about developmental needs of the infant knows that the parent has verbalized understanding of an infant's developmental needs when he states a. "My child is too young to understand words." b. "My child will begin to speak in sentences by 1 year of age." c. "My child will probably enjoy playing peek-a-boo." d. "While my child is in the hospital, I should let the nurses provide most of the care."
ANS: C By 9 months, infants play simple social games such as patty-cake and peek-a-boo. By 1 year, infants not only recognize their own names but are able to say three to five words and understand almost 100 words. Extended separations from parents complicate the attachment process and increase the number of caregivers with whom they must interact. Ideally, the parents provide most of the care during hospitalizations.
Which of these toys, if selected by the parent of a 10-month-old child, would indicate that the parent has a correct understanding of infant growth and development? a. A game requiring two to four players b. Electronic games c. Small, plastic alphabet letters and magnets d. Plastic stacking rings
ANS: D Adults facilitate infant learning by planning activities that promote the development of milestones and by providing toys that are safe for the infant to explore with the mouth and manipulate with the hands, such as rattles, wooden blocks, plastic stacking rings, squeezable stuffed animals, and busy boxes. Infants are not capable of participating in small group activities. By age 4, children play in groups of two or three. For the toddler (not the infant), television, videos, electronic games, and computer programs help support development and learning of basic skills. Adults should provide toys that are safe for the infant to explore with the mouth. Small, plastic letters and magnets could be choking hazards for an infant.
The mother of an infant born prematurely tells the nurse, the baby is irritable. He cries during diaper changes and feedings. Can you make some suggestions about what I should do to soothe him? the most appropriate recommendation to help this parent would be a. play the radio or tv while feed the baby b. put the baby in a room with sunlight c. cover the baby snugly when you hold him d. change the babys position quickly
Ans C A strategy that may be helpful is to swaddle the infant snugly in a light blanket with extremities flexed and hands near the face
The nurse would expect a 4 month old to be able to a. hold a cup b. stand with assistance c. lift head and shoulders d. sit with back straight
Ans C Because development is cephalocaudal, of these choices, sitting is the one that the infant learns to do first. the infant can usually sit with support at about 5 months of age and can sit alone at about 8 months
The statement that indicates the mother of an 8 month old understands infant sleep patterns is a. I put the baby in my bed until she falls asleep, then I put her in her crib b. I let the baby skip an afternoon nap so she will fall asleep earlier c. I put the pacifier in the crib so she can find it when she wakes up d. I rock the baby back to sleep if she wakes up at night
Ans C The parent should assist the infant to develop self-soothing behaviors so the infant can get back to sleep on her own
The most appropriate activity to recommend to promote sensorimotor stimulation for a 1 year old would be a. ride a tricycle b. spend time in an infant swing c. play with push pull toys d. read large picture books
Ans C push pull toys are appropriate to promote sensorimotor stimulation for a 1 year old child
When assessing development in a 9 month old infant, the nurse would expect to observe the infant a. sitting if supported b. grasping objects with the plan c. imitating sounds such as da da d. beginning to use a spoon rather sloppily
Ans C the 9 month old tries to imitate sounds such as da da or ba ba
The statement made by a parent that indicates correct understanding of infant feeding is a. I've been mixing rice cereal and formula in the babys bottle b. I switched the baby to low fat milk at 9 months c. The baby really likes little pieces of chocolate d. I give the baby any new foods before he takes his bottle
Ans D New solid foods should be introduced before formula or breast milk to encourage the infant to try new foods
A mother calls the pediatricians office because her infant is colicky. The helpful measure the nurse would suggest to the parent is a. sing songs to the infant in a soft voice b. Place the infant in a well lit room c. walk around and massage the infants back d. Rock the fussy infant slowly and gently
Ans D One technique the nurse can offer parents of a fussy infant is to rock the infant gently and slowly while being careful to avoid sudden movements.
The nurse is aware that the age at which an infant is able to sit steadily alone is a. 4 months b. 5 months c. 8 months d. 15 months
ANS C the infant can sit alone without support at about 8 months of age
The nurse would advise a parent when introducing solid foods to A. begin with one tablespoon of the food b. mix foods together c. eliminate a refused food from the diet d. Introduce each new food 4 to 7 days apart
ANS D only one new food is offered in a 4 to 7 day period to determine tolerance
The nurse cautions parents to place their baby in the ________or _______ positions, rather than on its stomach, to reduce the risk of sudden infant death syndrome (SIDS)
ANS supine or side-lying the supine or side lying position has been found to reduce possible aspiration, and is believed to reduce the risk of SIDS
the parent of a 3 month old infant asks the nurse, at what age do infants usually begin drinking from a cup? the nurse would reply a. 5 months b. 9 months c. 1 year d. 2 years
Ans A The infant can usually drink from a cup when it is offered at about 5 months
The nurse is aware that the age at which the posterior fontanelle closes is a. 2 to 3 months b. 3 to 6 months c. 6 to 9 months d. 9 to 12 months
Ans A The posterior fontanel closes between 2 and 3 months of age
The nurse observes a 10 month old infant using her index finger and thumb to pick up Cheerios. This behavior is evidence that the infant has developed the a. pincer grasp b. grasp reflex c. prehension ability d. parachute reflex
Ans A by 1 year, the pincer-grasp coordination of index finger and thumb is well establishsed
The nurse is aware that the 7 month old can signal feeding readiness by select all that apply a. pulling spoon toward mouth b. biting at spoon with upper and lower incisors c. pointing to food bowl d. bouncing up and down with excitement at sight of food e. manipulating finger foods
Ans A, E the 7 month old pulls the spoon toward its mouth and can manipulate finger foods. The 7 month old does not have upper incisors and has not developed adequately to recognize the food container of exhibit excitement related to the sight of food
The nurse would advise a mother who is concerned because her 10-month-old is lethargic to__________. a. keep the babys room well lit b. Rub the babys soles vigorously c. offer the baby a pacifer d. handle the infant slowly and gently
Ans D some infants respond to stimulating environments by shutting down. Move and handle infants slowly and gently
The neonatal nurse is assessing a term neonate in the delivery room. Which respiratory assessment finding at 15 minutes after birth causes the greatest concern to the nurse? 1. A single episode of apnea occurs for 18 seconds in a 1-minute period. 2. Respirations are irregular, sporadic, shallow, and diaphragmatic. 3. Acrocyanosis is pronounced in all four extremities. 4. Respiratory rate fluctuates between 30 and 60 breaths per minute.
ANS: 1 1 This is correct. Apnea, a cessation of breathing longer than 15 to 20 seconds, is indicative of an alteration in respiratory transitioning. This assessment finding is of greatest concern to the nurse. 2 This is incorrect. Irregular, sporadic, shallow, and diaphragmatic respirations are considered normal for a neonate. This finding is not a cause of concern for the nurse. 3 This is incorrect. Acrocyanosis in hands and feet is normal in the term infant in the first 24 to 48 hours. After 24 to 48 hours of life, this may be an indication of cardiac disease. This finding is not a cause of concern for the nurse at this point in time. 4 This is incorrect. Average respiratory rate at birth is 30 to 60 breaths per minute. This finding is not a cause of concern for the nurse.
The RN in a pediatric office is preparing to administer oral medication to an infant. Before the actual administration of the medication, which initial action does the nurse take? 1. Obtain an accurate weight of the infant. 2. Provide the caretaker with written information. 3. Assist the caretaker in holding the infant supine. 4. Acquire a calibrated syringe for administration.
ANS: 1 1 This is correct. Pediatric dosing must be precise to ensure adequate therapeutic levels; dosing is based on weight. The weight needs to be obtained first. 2 This is incorrect. The caretaker will be provided with written information, but this action can take place before or after the administration. 3 This is incorrect. The caretaker is asked to hold the infant during medication administration. The infant is held in a cradled position used for breast or bottle feeding. The infant is not laid in a supine position until he or she swallows all the medication. 4 This is incorrect. The nurse carefully calculates the correct dose and draws the medication up in a calibrated syringe to assure the exact dose is given. Caretakers are discouraged from using household spoons, because they vary in size and can result in over- or underdosing.
The nurse is interviewing a parent of a 9-month-old infant during a well-baby visit. Which statement by the parent causes the nurse concern about infant safety? 1. "He loves to get his toys out of a big plastic storage bag on the doorknob." 2. "He thinks the TV remote is a toy, so it is kept on a shelf too high for him to reach." 3. "When we eat cooked vegetables, I cut a few into bite size pieces so he can try them." 4. "It really disturbed me to see my neighbor's infant with a pacifier on a cord around the neck."
ANS: 1 1 This is correct. The nurse is concerned that the infant is getting toys out of a large plastic bag hanging on a doorknob. Plastic bags or wrappings are never kept where the infant can reach them because of the risk for suffocation or choking. If the bag is hung by a cord, there is an additional risk of choking. 2 This is incorrect. Swallowed batteries are a choking hazard and can cause serious damage to the GI tract if swallowed. The nurse is not concerned because the TV remote is kept out of the infant's reach. 3 This is incorrect. An infant who is 9 months of age can be safely given cooked vegetables cut into small bite-sized pieces. Pieces that are too large or too small can present a choking hazard. 4 This is incorrect. The parent's recognition that anything on a cord around an infant's neck is a choking hazard indicates an understanding about infant safety. The nurse can suggest that the information be shared with the neighbor.
The nurse is teaching a class to parents about emergency care for newborns and infants. Which comment from a parent indicates a need for additional teaching? 1. "I will apply gentle tourniquet pressure for serious extremity bleeding." 2. "The most important behavior is to remain calm and get emergency help." 3. "A seriously injured child is moved only if they are in a dangerous situation." 4. "If a seizure occurs, the safest place for the child is on the floor with the head turned."
ANS: 1 1 This is correct. The parent who describes applying a tourniquet in any manner for serious extremity bleeding needs additional teaching. When bleeding occurs with an infant, pressure with a clean cloth needs to be applied to the bleeding site. 2 This is incorrect. Additional teaching is not needed for the parent who understands the importance of remaining calm and getting help during an emergency situation. 3 This is incorrect. Additional teaching is not needed for the parent who understands that a seriously injured newborn/infant should only be moved if in a dangerous situation. Examples would be a burning building, in a car, or underwater. 4 This is incorrect. Additional teaching is not needed for the parent who understands that a seizing newborn/infant should be lowered to the floor and the head turned to the side. The nurse may remind the parents that nothing is placed in the mouth of a newborn/infant who is seizing.
The nurse is providing teaching to parents who are expecting their first child. For which reason does the nurse understand this teaching to be so important? Select all that apply. 1. It provides information that defines health and normalcy. 2. It instructs parents about general, safe infant care. 3. It helps reduce the appearance of regressive behavior. 4. It encourages development of parent-infant interactions. 5. It presents methods to help maintain infant/child health.
ANS: 1, 2, 4, 5 1. This is correct. The nurse includes developmental milestones, home infection control measures, the importance of immunizations, and the use of car seats and other safety equipment. 2. This is correct. The nurse will discuss general health-care concerns, such as nutrition, oral health, the need for sleep, and appropriate hygiene care. 4. This is correct. The nurse will share the importance of parent-infant interactions, including playing, cuddling, the importance of talking to the child, and separation anxiety. 5. This is correct. The nurse will share information about nutrition, oral health, prevention of illness and infections, prevention of injury, and childproofing the home. The nurse emphasizes the importance of learning infant/child CPR. The nurse will also cover the care for an infant/child that is ill. 3. This is incorrect. The nurse will help the parents with psychological preparation for the roles of caregiver, which is necessary to alleviate fears and anxiety in the care of the infant. Education for parents may help parents and family cope with sibling transition, including appearance of regressive behavior in siblings; however, this is the parents' first child.
A parent is concerned because her infant has a diaper rash. What is the best action the nurse would advise the parent to implement? a. Use commercial diaper wipes to clean the area. b. Apply a protective ointment on the area. c. Change the infant's diaper less frequently. d. Keep the diaper area covered all of the time.
Ans B A protective ointment can be applied when the skin in the diaper area appears pink and irritated
The nurse in a pediatric emergency department is concerned when parents bring a 9-month-old infant in for possible injury. X-rays indicate the infant has a broken leg. Which information causes the nurse to report possible physical abuse to the nursing supervisor? Select all that apply. 1. The infant has been treated three times for injuries. 2. The parents insist on simple, noninvasive medical care. 3. The father states the infant climbed a stepladder and fell. 4. The infant buries his face in the mother's arm if the father talks. 5. The mother states she fell down the stairs with the baby.
ANS: 1, 3, 4, 5 1. This is correct. Because of unexplained or repeated injuries such as welts, bruises, burns, fractured skull, broken bones, and especially spiral fractures, the nurse will report probable physical abuse to the nursing supervisor. 3. This is correct. When the father states the infant climbed a stepladder and fell, the nurse will suspect physical abuse, because injury explanation is unlikely given the age or ability of the child. The nurse will report the situation to the nursing supervisor. 4. This is correct. Fearful or detached behavior by the infant, especially when the father talks, is a probable sign of physical abuse. The nurse will report the behavior to the nursing supervisor. 5. This is correct. Disagreement or inconsistency in the parent/caregiver explanation of the injury can be an indication of physical abuse. The nurse can seek clarification about details of the accident and/or inquire about injury to the mother during the fall. The nurse is likely to report probable physical abuse of the infant. 2. This is incorrect. Neglect of the child (e.g., dirty, undernourished, inappropriate clothes for the weather, lack of medical or dental care) is indicated when the parents insist on simple, noninvasive medical care for a known diagnosis, such as a broken leg.
The nurse is preparing to teach to parents the importance of play in the newborn's and infant's life. Which information will the nurse plan to include in the class? Select all that apply. 1. Play is how infants learn about their environment and themselves. 2. Infants may be startled by their own images in a reflective toy. 3. Older siblings are encouraged to share their toys with the infant. 4. Toys should provide a means of sensory stimulation for the infant. 5. Toys can help with physical and fine motor development.
ANS: 1, 4, 5 1. This is correct. The nurse needs to explain that play is an important part of an infant's/child's development process. Play promotes learning about the environment and self. 4. This is correct. Infants explore the world with their mouths and imitate those around them. It is important to provide toys to initiate and promote learning through these methods. 5. This is correct. Physical development is promoted through play activities. Early on, infants will begin to develop gross and fine motor development; toys should be selected that will promote this type of learning. 2. This is incorrect. Infants love to look at their image in a mirror or shiny surface; this activity promotes learning about self. It would be unusual and unexpected for an infant to be startled by their own image. 3. This is incorrect. Infant toys are carefully selected for safety and age appropriateness. The toys of older siblings may have characteristics that present safety concerns.
The parent of an infant reports to the nurse a suspicion that the babysitter is neglecting the infant. The parent states, "I saw some disturbing things on a hidden nanny-cam." The nurse will support the decision to replace the babysitter if which behavior is observed? Select all that apply. 1. The infant is in the crib and ignored until time for the parent to arrive home. 2. The babysitter takes the infant out in the stroller for 1 hour on a cool day. 3. The infant cries and is given a bottle, which is propped up in the crib. 4. When the infant drops toys on the floor, the sitter tosses them back into the crib. 5. Prescribed medication is not given to the infant according to written instructions.
ANS: 1, 5 1. This is correct. Consistent failure to respond to the child's need for stimulation, nurturing, encouragement, and protection, or failure to acknowledge the child's presence, is indicative of neglect. This observation would warrant support from the nurse to replace the babysitter. 5. This is correct. Failure to provide the infant with prescribed medication according to written instructions is considered neglect and warrants replacement of the babysitter. 2. This is incorrect. Taking the infant out in the stroller on a cool day is not considered neglect unless the infant is not dressed appropriately. 3. This is incorrect. Propping a bottle is not alone considered to be neglect; the absence of nurturing is more closely related to neglect. 4. This is incorrect. When the babysitter tosses toys back into the crib after the infant drops them on the floor there may or may not be an indication of neglect. Further evaluation of the attitude, manner, and verbal response is needed.
The nurse in the neonatal care unit notices that a term neonate has a respiratory rate of 66 breaths per minute and exhibits pallor and lethargy. Which action does the nurse take immediately? 1. Unwraps the neonate and assesses for the presence of hypotonia. 2. Wraps in an additional blanket and puts a knitted cap on the neonate. 3. Takes the neonate to the mother and assesses sucking reflex during a feeding. 4. Contacts the neonate's physician and seeks permission to take a rectal temperature.
ANS: 2 2 This is correct. The initial assessment findings of the neonate are indicative of cold stress. Immediately, the nurse needs to take actions that will conserve body temperature. A knitted cap will cover the largest exposed area for heat loss; wrapping an additional blanket around the neonate will preserve heat. 1 This is incorrect. The initial assessment findings of the neonate are indicative of cold stress. Hypotonia is also a manifestation of cold stress, and the condition can exacerbate cold stress. An immediate action by the nurse is not to unwrap the neonate. 3 This is incorrect. An additional sign of cold stress is a poor sucking reflex. The nurse can assess for this manifestation in the nursery, and care should not be delayed by transporting the neonate to the mother for sucking evaluation. The immediate action is to decrease heat loss. 4 This is incorrect. Rectal temperature is obtained after birth to ascertain anal patency and is repeated only if prescribed by the physician and then with great care. The nurse can obtain an axillary temperature. Immediate nursing actions are to decrease heat loss; additional assessments can be performed after efforts to preserve body heat.
The nurse discusses safety proofing the home with the mother of a 9 month old. the statement made by the mother that indicates an unsafe behavior is a. I put covers on all of the electrical outlets b. In the car, she rides in a front facing car seat c. There are locks on all of the cabinets in the house d. I have a gate at the top and bottom of the stairs
Ans B A rear facing infant car seat should be used for infants under 1 year of age
A parent brings a 6-month-old infant to the pediatric clinic for her well-baby examination. Her birth weight was 8 pounds, 2 ounces. The nurse weighing the infant today would expect her weight to be at least _____ pounds. a. 12 b. 16 c. 20 d. 24
Ans B Birth weight is usually doubled by 6 months of age
The nurse is providing care for a newborn who was delivered at 34 week's gestation. The nurse understands the newborn is a greater risk for death or chronic care needs. Which recommendation does the nurse make to the parent to prevent the newborn from developing a common complication? 1. Strictly limit the newborn's exposure to persons outside the family for 6 months. 2. Start a series of palivizumab prophylaxis immunization as advised by the pediatrician. 3. Strongly express the need for more frequent pediatric visits to prevent complications. 4. Reinforce not allowing the premature newborn to cry for more than 10 minutes.
ANS: 2 2 This is correct. The prevention for RSV (a common complication for premature neonates) is palivizumab (Synagis) prophylaxis immunization; there are significant benefits to premature infants and infants who are less than 35 weeks. Palivizumab is given in no more than five monthly doses during RSV season (late October to late January). 1 This is incorrect. There is no protocol that supports the nurse recommending strict limitation of the newborn's exposure to persons outside the family for 6 months. However, the nurse should state that the presence of sick persons, and public exposure in general, increases the risk of illness in a premature newborn. 3 This is incorrect. There is no basis for the nurse to strongly express the need for more frequent pediatric visits to prevent complications. 4 This is incorrect. There is no basis for the nurse to reinforce not allowing the premature newborn to cry for more than 10 minutes.
The nurse in a community pediatric clinic screens for conditions that cause concern for possible infant abuse or neglect. Which situation will prompt the nurse to recommend parenting education? 1. The stay-at-home mother of four children (ages 4 to 16 years) who is bringing home a newborn. 2. The teenage couple with a newborn who live apart, but the father babysits during the day so the mother can attend school. 3. The newly relocated couple with a young infant who are now 12 hours away from family and friends. 4. The parents of an infant who live apart because the father of the infant is married and has a family with his wife.
ANS: 2 2 This is correct. The teenage couple with a newborn will cause the nurse the greatest concern about infant abuse or neglect. Because the couple live apart, the father is not exposed to the infant except when he is babysitting; unfamiliarity with the infant's behaviors or needs can lead to neglect. Frustration related to a lack of knowledge and/or immaturity places the infant at risk for abuse. The nurse needs to strongly recommend a program such as daddy boot camp to this couple. 1 This is incorrect. The stay-at-home mother of four children (ages 4 to 16 years) and a newborn does not cause the nurse concern about abuse or neglect. 3 This is incorrect. The newly located couple with an infant will cause the nurse mild concern. Further assessment is needed regarding the mother's emotional and psychosocial needs. Technology allows close connections with family and friends who are located far away. 4 This is incorrect. The volatility of the situation surrounding the birth of this infant may or may not cause the nurse concern over the risk of infant abuse and/or neglect. Further assessment is needed.
The nurse is providing care for a hospitalized infant who is 4 months of age. While making a plan of care for the patient, which interventions specific to the patient's age will the nurse include? Select any that apply. 1. Encourage caregivers to go home to rest and sleep. 2. Suggest a favorite or comfort item be brought from home. 3. Plan for invasive procedures to be performed in a treatment room. 4. Monitor the infant for behaviors and cues indicating separation anxiety. 5. Educate caregivers to leave the side rails of the crib down during the day.
ANS: 2, 3 2. This is correct. Even at 4 months, a familiar item from home provides comfort to the infant. The caregiver needs to bring a favorite toy or blanket. 3. This is correct. The nurse will make arrangements in the plan of care to perform all painful or invasive procedures in a treatment room. Performing such procedures at the crib site will create anxiety for the infant whenever the nurse approaches. 1. This is incorrect. The nurse should make arrangements in the plan of care for the caregiver(s) to room in with the hospitalized infant. 4. This is incorrect. At 4 months of age, the infant is not likely to experience separation anxiety, which most commonly occurs at 6 months of age. 5. This is incorrect. The nurse will include safety teaching to the caregivers in the plan of care. Safety risks in the hospital, such as lowered crib rails, the infant's crawling on the floor, or the presence of items that may not be in the infant's home need to be addressed. Crib side rails need to be up, especially if the infant is alone in the room.
The nurse is providing counseling to the caregivers of a 4-year-old child who was born with a genetic condition that interferes with physical and psychosocial development. The child has had multiple hospitalizations for illnesses and infections related to the genetic condition. For which reasons will the nurse suggest the caregivers consider placement in a pediatric medical home? Select all that apply. 1. The caregivers will be relieved of care needed for 24 hours every day. 2. The home is set up to provide pediatric care from birth to adulthood. 3. The child's medical history indicates health risks related to family care. 4. The model is designed to reflect care standards suggested by pediatricians. 5. Care is coordinated by an interdisciplinary team that includes the caregivers.
ANS: 2, 4, 5 2. This is correct. The pediatrician-designed model of the pediatric medical home involves providing care to patients from birth to adulthood. 4. This is correct. The AAP developed the pediatric medical home model to deliver primary care to the child and family in a coordinated and comprehensive approach. 5. This is correct. A medical home integrates and coordinates care through interdisciplinary coordination with the child, family, primary physicians, specialists, hospitals, health-care systems, public health, and the community. 1. This is incorrect. The nurse may be concerned about caregiver stress and fatigue; however, the nurse focuses primarily on the needs of the patient. 3. This is incorrect. The nurse is not judgmental about family care and does not place blame on the caregiver's for the patient's unstable health. The state of the patient's health, and the necessary care, is not provided in detail.
The infant should be able to walk independently by the age of A. 8-10 months B. 12-15 months C. 15-18 months D. 18-21 months
Ans B For the majority of children, the milestone of walking alone is achieved between 12 and 15 months
The nurse knows that an infants birthweight should be tripled by a. 9 months b. 1 year c. 18 months d. 2 years
Ans B The infant usually triples his or her birth weight by 12 months of age
The abnormal finding in an evaluation of growth and development for a 6 month old infant would be a. weight gain of 4-7 ounces per week b. length increase of 1 inch in 2 months c. head lag present d. can sit alone for a few seconds
Ans C The infant should be holding the head up well 5 months of age. If head lag is present at 6 months, the child should undergo further evaluation
The nurse is assessing an infant at 1 month of age. At birth the infant weighed 7 pounds 10 ounces. Which is the minimum weight the nurse will expect during this assessment? 1. 8 pounds 2 ounces 2. 8 pounds 10 ounces 3. 8 pounds 14 ounces 4. 9 pounds 6 ounces
ANS: 3 3 This is correct. Birth to 1 month, the infant is expected to gain a minimum of 5 ounces weekly. The minimum expected weight for the infant weighing 7 pounds 10 ounces at birth is 8 pounds 14 ounces. 1 This is incorrect. Birth to 1 month, the infant is expected to gain a minimum of 5 ounces weekly. The weight of 8 pounds 2 ounces is below the expected minimum weight. 2 This is incorrect. Birth to 1 month, the infant is expected to gain a minimum of 5 ounces weekly. The weight of 8 pounds 10 ounces is below the expected minimum weight 4 This is incorrect. Birth to 1 month, the infant is expected to gain a minimum of 5 ounces weekly. A weight of 9 pounds 6 ounces is the maximum expected weight for the infant weighing 7 pounds 10 ounces at birth. Normal weight gain during the first month is 5 to 7 ounces weekly.
A neonate is delivered 3 weeks before the due date. The nurse performs assessment of gestational age by using the Ballard maturational scoring tool. Which assessment result indicates a premature infant? 1. A rating of the highest scores for physical maturity and neuromuscular activity 2. A rating of the lowest scores for physical maturity and neuromuscular activity 3. A rating of the lowest scores based on weight, length, and head circumference 4. A rating of the highest scores based on weight, length, and head circumference
ANS: 3 3 This is correct. The scores for the assessments are plotted on a graph to provide a gestational age based on weight, length, and head circumference to determine if the neonate is appropriate for gestational age. Term neonates have higher scores than premature neonates. Premature neonates have lower scores; being born at 37 weeks' gestation does indicate prematurity. 1 This is incorrect. The lowest score from all the assessments needs to be based on the physical size of the neonate and does not include neuromuscular assessment. 2 This is incorrect. The highest score from all the assessments needs to be based on the physical size of the neonate and does not include neuromuscular assessment. 4 This is incorrect. The scores for the assessments are plotted on a graph to provide a gestational age based on weight, length, and head circumference to determine if the neonate is appropriate for gestational age. Term neonates have higher scores than premature neonates.
The nurse in a pediatric clinic is preparing to assess an infant at the age of 9 months. The nurse is aware that this well-baby checkup will involve assessment for developmental delays or disabilities. Which finding causes the nurse to suspect a developmental delay? 1. Displays sucking reflex when presented with bottle or pacifier. 2. Cries and reaches for the parent when placed on the examination table. 3. Loses interest in an object that is dropped out of sight by the nurse. 4. Waves or shakes the head in response to verbal cues "bye-bye" and "no."
ANS: 3 3 This is correct. When a 9-month-old infant loses interest in an object that is dropped out of sight by the nurse, the nurse is concerned by a possible developmental delay. At 9 months of age the infant is expected to know where to look for an object that has been dropped. 1 This is incorrect. This does not suggest a developmental delay. The sucking reflex does not disappear until 10 to 12 months of age. 2 This is incorrect. By the age of 9 months and 1 year, an infant is more comfortable with familiar surroundings and people and expresses dissatisfaction with strangers or strange surroundings (stranger anxiety). It is not concerning for the infant to display this behavior 4 This is incorrect. Around 9 months the infant is expected to say "Dada" and "Mama" and understands bye-bye and no. The nurse is not concerned by the infant's response.
The nurse is providing care for a neonate who is identified as being at risk for neonatal abstinence syndrome. Which assessment finding causes the nurse to expect pharmacological interventions for this neonate? 1. Central and autonomic nervous system irritability and dysfunction are present. 2. The Finnegan neonatal abstinence score is 7 at 3 hours after birth. 3. Symptoms are not alleviated with swaddling, comforting, and feeding. 4. The Finnegan neonatal abstinence score is 10 at 3 hours after birth.
ANS: 4 4 This is correct. The Finnegan neonatal abstinence score of 10 at 3 hours after birth is the strongest indicator of the need for pharmacological interventions for this neonate. Pharmacological interventions are with morphine sulfate or methadone adjusted based appropriately for scores greater than 8. 1 This is incorrect. Central and autonomic nervous system irritability and dysfunction is an expected finding in the neonate with abstinence syndrome. 2 This is incorrect. A Finnegan neonatal abstinence score of 7 at 3 hours after birth is not an indication for pharmacological intervention. 3 This is incorrect. The American Academy of Pediatrics (AAP) recommends opioid replacement therapy for infants who do not respond to nonpharmacological management; however, there is a more accurate indicator in this scenario.
During hospitalization, the nurse should encourage the parents of an 8-month-old infant to a. Provide as much care as possible. b. Not worry about attachments because the infant is too young to develop them. c. Remember that infants cannot differentiate a stranger from a familiar person. d. Relax and allow nursing staff to care for the child at all times.
ANS: A Extended separations from parents complicate the attachment process and increase the number of caregivers with whom the infant must interact. Ideally, the parents provide most of the care during hospitalizations. Close attachment to the primary caregivers, most often parents, usually occurs by this age. Infants seek out these persons for support and comfort during times of stress. By 8 months, most infants are able to differentiate a stranger from a familiar person and respond differently to the two.
The nurse explains that a babys prehensile development is progressive and logical. Arrange the development in the order from the simplest to the most complex. a. hands held open most of the time b. Grasps with thumb on one side and three fingers on the other c. Picks up toy with squeeze action d. Thumb and forefinger hold object e. Hands held closed most of the time
ANS: E, A, C, B, D the development advances from the newborns closed hands to the open star hands of the older infant, to the squeeze action to a grasp with thumb and fingers, to the pincher movement of thumb and forefinger
The nurse reminds the parents that the first DpT, oral polio, and flu immunizations should be given when the child is ________months old.
Ans 2
When talking with a parent about eruption, the nurse explains that the first deciduous teeth to erupt are the A. lower central incisors b. Upper central incisors c. Lower lateral incisors d. Upper lateral incisors
Ans A The first teeth to erupt, usually at about 7 months, ae the lower central incisors
The nurse explains the second process of self mobility a baby learns is seen at the age of 9 months, when the baby begins to _____.
Ans: Creep At 7 months the baby begins to crawl, using arms and dragging trunk and legs. At 9 months the baby begins to creep holding its trunk above the floor. The next self-mobility activity is cruising, where the child walks from one piece of furniture to the next before it begins to walk independently.
