Prep Chp 15

The nurse is completing an assessment on a 2-year-old child. The nurse notes the presence of a raised reddish purple spot on the back of the child's neck. Which statement about this finding is correct?

These lesions will normally fade as the child ages. The lesions described are consistent with strawberry nevus. They are benign and normally fade as the child ages, usually by the age of 9 years. Nevus flammeus are associated with the development of Sturge-Weber syndrome.

The nurse is working closely with a premature infant who will be discharged home soon on oxygen and cardiac/respiratory monitoring. Which comments by the parents indicate that discharge instructions were understood? Select all that apply.

• "It's important that we continue to bathe and dress our baby like you taught us." • "We need to follow our planned feeding schedule as closely as possible." • "We feel like we know how to respond to the alarms on the equipment." • "We will refer back to our discharge instructions if we are trying to determine if we need to notify the doctor about a change in our baby." The nurse would educate the family on routine newborn care while considering the additional teaching regarding newborn care with the added cardiac, respiratory equipment. The parents would also need specific and detailed information regarding the alarms and how to respond to an alarm. Smoking would not be allowed at any time in the home

A 6-month-old has fanning of the toes and dorsiflexion of the big toe seen on physical exam. Based on this finding the nurse should:

document as a normal finding. The infant should be assessed for a Babinski reflex. To achieve this stroke the sole of the foot. Fanning of the toes will occur in infants younger than 3 months of age. A downward reflex of the toes will occur beyond 3 months of age. Some infants will demonstrate a flaring Babinski sign until 2 years of age. In the absence of other neurologic findings this is a normal response. The nurse would document this normal finding. The child would not need to be referred for further evaluation. The finding does not indicate any particular type shoe the child would require.

A nurse is providing health promotion education to a family of an 11-month-old infant who is eating "finger foods." The nurse knows the parents understand the risk of infant choking when they state which response below?

"I can feed our baby Cheerios. "Explanation:Cheerios are a good choice for finger-foods to promote finger-grasp fine motor coordination and self-feeding. Ten to 12 months is a good age to promote self-eating as infants move into mostly solid foods. Popcorn, raisins, and lollipops are choking hazard foods for infants at this age.

The nurse is providing teaching to the parents of a newborn prior to a heelstick. The nurse is describing the procedure and recommending various methods for the parents to help comfort their baby. Which statement by the parents indicates a need for further teaching?

"It's better if we are not in the room for this." Unless contraindicated, the parents should be encouraged to be present before, during, and after the procedure to provide comforting support to the child. Skin-to-skin (kangaroo) care, small-gauge needles, and nonnutritive sucking are other methods to provide atraumatic care.

The nurse is providing anticipatory guidance to a mother of a 5-month-old boy about introducing solid foods. Which statement by the mother indicates that effective teaching has occurred?

"The cereal should be a fairly thin consistency at first." Iron-fortified rice cereal mixed with a small amount of formula or breast milk to a fairly thin consistency is typically the first solid food used. As the infant gets older, a thicker consistency is appropriate. Strained, pureed, or mashed meats may be introduced at 10 to 12 months of age. A cup is typically introduced at 6 to 8 months of age regardless of what or how much solid food is being consumed.

The parents of a 12-month-old child tell the nurse the child has stopped walking and is now only crawling or sitting with support. How should the nurse respond?

"This is a concern. Let's be sure the physician is aware of this change." Children who have previously met a developmental milestone and then lose that milestone need an immediate and full evaluation due to the concern of significant neurologic problems. Children do often regress in behavior when under stress (hospitalization, new baby in the home, etc) but should not completely lose a milestone. Three months is too long to wait for additional evaluation. Children do develop at different rates, but this child had already met a milestone so this response is inappropriate.

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 most appropriate?

"What does his stool look like?" Grunting, crying and straining during bowel movements by infants and newborns is normal. This is due to the immaturity of the gastrointestinal system. The most important thing to do initially is to determine the appearance of the stool. The grunts and cries are not of concern unless the stool is dry and hard, so asking about the characteristics is the initial response. Simply indicating this is normal without having additional information is not the appropriate response. There is no need for a stool specimen based upon the information provided.

The infant weighs 6 lb 8 oz (2,950 g) at birth. If the infant is following a normal pattern of growth, what would be an expected weight for this child at the age of 12 months?

19 lb 8 oz (8825 g) The average newborn weighs 7.5 lb (3400 g). The average newborn loses 10% of birth weight over the first week of life but regains it in about 10 to 14 days. Most infants double their birth weight by 4 to 6 months of age and triple their birth weight by the time they are 1 year old. If the newborn weighed 6 lb 8 oz (2,950 g) at birth and tripled that weight at 12 months, the infant should weigh 19 lb 8 oz (6.5 lb × 3 = 19.5 lb) or 8825 g.

The nurse is assessing a 9-month-old child that was born at 32 weeks' gestation. The nurse is aware that the child's growth and development expectations would be at what age group?

7 months old When assessing growth and development of an infant or child, determine the child's adjusted or corrected age. To determine this age, subtract how early the child was delivered by the child's chronological age. In this question, the child was born at 32 weeks' gestation or 2 months early, so subtract 2 months from 9 months.

The English-speaking nurse is assessing a 12-month-old child with an English-speaking father and a Spanish-speaking mother. The child does not use words like "drink" "dog" or "ball." What is the nurse's priority intervention?

Asking the mother if the child uses Spanish words for those items Infants in bilingual families may use some words from each language. Therefore, the priority intervention in this situation would be to ask the mother if the child uses Spanish words. There is not enough evidence to warrant performing a developmental evaluation or referring the child to a developmental specialist. Encouraging the parents to speak only one language to the child is unnecessary if the child is progressing with both.

A newborn requires skin care that includes bathing. Besides hygiene, what is another reason for bathing the newborn?

Bathing is a time for bonding with the parents. The parents can use bath time for bonding with their newborn. This can be done with talking, cooing, and singing. Bath time should be slow-paced and nonstressful. Newborns prefer interacting with parents over toys and they love to watch people's faces. Bathing can help prevent infection, but it is a secondary response. Using soaps on the skin tends to dry the skin, not moisten it. After bathing, lotion can be applied. It is soothing to the baby and keeps the skin softened.

The nurse is preparing to administer a diphtheria, tetanus and pertussis vaccine to a 3-year-old child. Which version of the formulation of the vaccine should be administered?

DTaP The vaccine currently used for children younger than age 7 is diphtheria, tetanus, acellular pertussis (DTaP). The older version of this vaccine was DPT. Diphtheria and tetanus (DT) vaccine is used for children younger than age 7 who have contraindications to pertussis immunization. The TdaP is used clients over the age of 7.

Mark is a 2-month-old infant who is receiving formula. He has inconsolable crying, is gassy, and constantly draws his legs up. It has been determined that Mark has colic. Which of the following would be most appropriate?

Encourage the use of a different formula to assess for sensitivity. Colic peaks between 6 weeks of age and stops at about 3 months. In breastfed infants, colic sometimes is a reaction to something the mother has eaten. In other infants, colic may result from sensitivity to milk or milk products. Treatment is a restful, soothing environment. Changing an infant's formula or having a breastfeeding mom decrease her intake of gassy foods may alleviate the symptoms.

What mineral is an important factor in tooth development?

Fluoride Fluoride is important for the growth and protection of teeth. Fluoride is available in most drinking water. If the water source does not contain fluoride, then supplements can be given as prescribed by a health care provider, beginning at 6 months of age.

The nurse is examining a 6-month-old girl who was born 8 weeks early. Which finding is cause for concern?

Head size increased 5 inches since birth. The child's head size is large for his adjusted age of 4 months, which would be cause for concern. Normal growth would be 3.6 in (9 cm). At 10 lb, 2 oz (12 cm), the child is the right weight for a 4-month-old adjusted age. Palmar grasp reflex disappears between 4 and 6 months adjusted age, so this would not be a concern yet. The child is of average weight for a 4-month-old adjusted age.

An 8-month-old will be hospitalized for surgery. Which preparation by her parents would be most important?

Pack her favorite toy. A favorite toy helps provide comfort and decrease the effect of separation.

The nurse is preparing to give a 4-month-old an oral medication. Which technique demonstrates the nurse's accurate knowledge of the infant's developmental level?

Position the infant upright, offer the infant a bottle of formula, remove the bottle and squirt the medication on the side of the tongue toward the cheek, then offer the infant the bottle again. Proper medication administration for an infant includes the following: Position the infant upright, present a pleasant- or neutral-tasting substance to ensure that the child is awake and swallowing, give the medication slowly enough to allow the child to swallow and prevent any risk of aspirating, and give a pleasant-tasting "chaser." An infant should not be placed supine since this would increase the risk of aspiration. Medications should not be placed in a client's staple food to avoid an aversion to the food in the future.

The clinic nurse is assessing a 9-month-old client. The parents state, "Our baby is having a really hard time teething." Which nursing action is appropriate?

Recommend the parents provide the infant a cold teething ring to chew Chewing on a cold ring can be very soothing for the tender gumlines during teething. Warm foods offer no relief from teething. Numbing agents are not recommended as they increase the risk of choking. Acetaminophen should not be administered routinely. It may be given every 4 to 6 hours as needed.

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

Sitting without support Physical development of infants occurs in a cephalocaudal fashion. That means they must learn to control and lift their heads first. This is followed by the ability to turn over. Once this occurs the remainder of development occurs quickly. Most infants are able to sit unsupported by 8 months. They are able to creep at 9 months and pull to a standing position by 10 months. At 12 months the infant is able to sit from a standing position and is learning to walk.

The nurse is examining the genitals of a healthy newborn girl. The nurse should observe which normal finding?

Swollen labia minora The newborn's labia minora is typically swollen from the effects of maternal estrogen. The minora will decrease in size and be hidden by the labia majora within the first weeks. Lesions on the external genitalia are indicative of sexually transmitted infection. Labial adhesions are not a normal finding for a healthy newborn. Swollen labia majora is not a normal finding.

The nurse is conducting home visits for several families with children born prematurely. When screening for growth and development of the children, the nurse would use the infant's corrected age for which child?

The 24-month-old born at 28 weeks' gestation When screening and assessing growth and development, the nurse would use the child's corrected age (age - weeks early) until the age of 3. After the age of 3, the nurse would use the child's chronological age (the actual age of the child) to assess/screen for G/D.

The nurse is assessing reflexes on a neonate. When assessing, which reflex is the nurse most correct to clap during the assessment technique?

The Moro reflex The Moro or startle reflex is tested by making a loud sound or moving the crib. The infant will extend and flex arms quickly.

A parent asks if her newborn's undescended testicles will need surgery to repair. What is the best response by the nurse?

There is a chance the testicles will descend on their own. The AAP recommends surgery at 1 year of age if the testicles have not descended on their own. There is a chance they may descend on their own prior to 1 year old. This problem does not cause pain or swelling.

The best way for an infant's parent to help the child complete the developmental task of the first year is to:

respond to the infant consistently The developmental task of an infant is gaining a sense of trust. The infant develops this sense from the caretakers who respond to the child's needs, such as feeding, changing diapers, being held. It is a continuous process. A sense of trust is difficult to learn if things are constantly changing. Consistently responding to an infant's needs helps to build a sense of trust. An infant is too young to have variability in caretakers. This causes mistrust. The parents or caretakers do not need a special time to talk to the infant each day. It should be done with each interaction. Providing too much stimulus before the infant develops gross motor skills causes frustration from the child and not enjoyment.

A mother is concerned about her infant's spitting up. Which suggestion would be most appropriate?

"Keep the baby sitting up for about 30 minutes afterward." Keeping the baby upright for 30 minutes after the feeding, burping the baby at least two or three times during feedings, and feeding smaller amounts on a more frequent basis may help to decrease spitting up. Positioning the infant in an infant seat compresses the stomach and is not recommended.

The home care nurse is conducting the final home care visit before a scheduled delivery. The client states, "My baby will not receive any shots, because I do not believe in them!" What is the most appropriate response by the nurse?

"Immunization helps keep children healthy and from getting diseases." The nurse should remind the client the importance that immunizations have in the overall health of children and global populations. Nurses can also provide appropriate information regarding which immunizations the infant will receive immediately after birth and what the immunization schedule is.

The nurse is caring for an infant who was injured in a severe automobile accident. The child experienced several fractures and is in significant pain. The child's mother questions if this will impact her child later in life. What information should be provided by the nurse?

Experiences with pain even in infancy can influence an individual's response to pain later. Repeated exposure to painful procedures and events can have long-term consequences. Memories of pain may be stored in the child's nervous system, influencing later reactions to painful stimuli.

To obtain an accurate heart rate in an infant, what would be most important for the nurse to do?

Take the apical pulse. Taking the apical pulse with a stethoscope and counting the rate for a full minute is the most accurate way to obtain the heart rate on an infant. The radial pulse should only be taken with older children, as it is difficult to palpate accurately in children younger than 2 years of age because the blood vessels lay close to the skin surface and are easily obliterated. An electronic stethoscope is not necessary to listen to heart sounds and count an apical pulse.

All infants should have their head circumference measured at health assessment visits. Where should the nurse place the tape measure to obtain this measurement?

just above the eyebrows through the prominent part of the occiput To measure the circumference of an infant's head, the nurse would measure the largest point across the skull, not including the ears, with a nonstretching cloth or paper tape. The tape would be placed at the forehead just above the eyebrows and brought around the head in a taut circle just above the occiput prominence at the back of the head. The measurement is then marked on a growth chart so it can be plotted to assess adequate growth. Each of the other options depict incorrect placement of the tape for measurement and would not provide a correct measurement of the head.