PrepUs for Pediatrics Chapter 23
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 nurse should reinforce that stuffed animals, blankets, pillows, and soft mattresses are suffocation hazards for infants.
A home visit nurse is providing health promotion on safety to a family of a 1-week-old infant. Which of the following statements by the parents indicates the need for further teaching?
"We will position our infant on his side for sleeping." Infants should be placed on their backs for sleeping to reduce the risk of SIDS. All other choices are safe infant practices.
The nurse is teaching the parents of an infant about bathing. The nurse will inform the parents to set the home hot water heater to which temperature?
115°F (46.1℃) Water safety also includes ensuring the home hot water heater temperature is set to less than 120°F (48.9°C) to prevent burns and scalding of the infant while bathing
In working with infants, the nurse would expect the posterior fontanel to be closed in an infant who is which age?
3 months The posterior fontanel is usually closed by the second or third month of life.
The nurse is helping the mother of a 5-month-old boy understand the importance of developmentally appropriate play. Which one of the toys best meets the needs of this child?
A yellow rubber duck for the bath The rubber duck is most appropriate. It is safe, visually stimulating while bobbing on the water, and adds pleasure to bath time. A push-pull toy promotes skill for a walking infant. Pots and pans from the kitchen cupboard are played with successfully after sitting is mastered. A 5-month-old does not have the fine motor coordination to use stacking toys.
The nurse is assessing a 12-month-old boy with an English-speaking father and a Spanish-speaking mother. The boy does not say specific words such as mama or dada yet. What is the priority intervention?
Asking the mother if the child uses Spanish words 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 English to the child is unnecessary if the child is progressing with Spanish first.
Which measures should receive priority in the care plan for an infant client who has sensitive skin?
Change diapers frequently The infant should be changed every 2-4 hours. It is best to use unscented wipes or clear water to clean the infant with each change. Baby power should never be used as it is an aspiration risk.
A mother calls the clinic every couple of weeks concerned that her infant is not developing appropriately. What would be an appropriate nursing diagnosis for the nurse to assign to this client?
Deficient knowledge related to normal infant growth and development The client is demonstrating deficient knowledge related to normal growth and development of her infant. The nurse should plan interventions that include teaching of expected outcomes of growth and development.
A 3-month-old infant has a Moro reflex. Which statement is most true of this reflex?
Most 3-month-old infants still have a Moro reflex. The Moro reflex is seen in the infant as a sudden extension of the head with the arms abducted and moving upward. In this position the hands for the letter "C". This reflex is present at birth and disappears around 4 months of age. This reflex is known as the startle reflex because the baby looks startled when this is seen. It is a normal reflex and there is no need for medical intervention.
The parent of a 3-month-old infant is concerned because the infant does not yet sit by oneself. Which statement best reflects average sitting ability?
Most infants do not sit steadily until 8 months; this infant is normal. At 3 months of age the infant should be able to raise the head about 45 degrees when in the prone position. The infant does yet have the developmental skills for sitting. Most infants are unable to sit steadily until 8 months of age. Gross motor skill development does not correlate with tooth eruption. The nurse should reassure the parent that this infant is on tract developmentally.
The nurse is teaching a parenting class to a group of first-time mothers. She recommends which of the following as positive caregiver-infant interactions? Select all that apply.
Mother offers adequate types and amounts of food for the infant. Mother holds the infant in an appropriate position while feeding. Mother burps the baby during and after feeding. Mother provides age-appropriate toys for the infant. The mother should talk to the infant, which provides for bonding and stimulation of the developing infant. The other choices are all correct.
A nurse is instructing the mother of a newborn about bathing and skin care. When discussing bathing, the nurse includes which of the following besides hygiene as an important reason for bathing?
Promoting parental bonding The parents can use bath time for bonding with their infant. This can be done with talking, cooing, and singing. Bath time should be paced and non-stressful.
In providing anticipatory guidance related to choking hazards for infants, what should the nurse include in the teaching? Select all that apply.
Raw carrots Plastic bags Propping a bottle
If the infant is following a normal pattern of dentition, the child would most likely have how many teeth by the age of 14 months?
Six to 12 teeth The central incisors erupt between 6 and 12 months of age and lateral incisors erupt between 9 and 13 months. The other lateral incisors erupt between 10 and 16 months, so by age 14 months the infant could have up to 12 teeth.
What action shows an example of Erik Erikson's developmental task for the infant?
The infant cries and the caregiver picks the child up. Erikson's psychosocial developmental task for the infant is to develop a sense of trust. The development of trust occurs when the infant has a need and that need is met consistently. Crying with a wet diaper without a change of the diaper leads to an unmet need. Playing peek-a boo and smiling are developmental tasks that indicate a normal healthy, happy baby. These would be attributed to Piaget theory.
The nurse is conducting a physical examination of a 5-month-old boy. Which observation may be cause for concern about the infant's neurologic development?
The infant displays an asymmetric tonic neck reflex (fencing reflex). The tonic neck reflex normally disappears by age 4 months, the palmar grasp reflex by age 6 months, and the Babinski reflex (fanning of toes when sole of foot stroked) by 12 months. Retaining these primitive reflexes may indicate a neurologic abnormality. The anterior fontanel, which remains open for brain growth, closes between 12 and 18 months of age.
A parent asks the nurse what symptoms to expect with normal teething in the infant. How should the nurse respond?
The infant's gumline will be tender. Infants experience discomfort as the tooth emerges through the peridontal membrane and from inflammation. When teething some infants become irritable, have excessive drooling and like to bite on hard surfaces. To relieve discomfort the parent can apply ice to the gums or use an over-the-counter topical anesthetic for infants. Some infatns will refuse to eat or have poor sleeping due to the pain in the gums. There is not a definitive timeframe for this to occur, and it does not happen in all infants. Fever, diarrhea, and vomiting are signs of illness, not teething.
An infant who is 4 months old continues to be seen at doctor visits for illness prevention. What would be the next scheduled appointment that this infant should attend to be evaluated?
The next visit would be at 6 months. The routine schedule for newborn visits within the first year of life is at 1 week, and then at 1, 2, 4, 6, 9, and 12 months of age. The above infant should be seen at 6 months of age for follow-up care and instructions.
The nurse conducting a 6-month well-baby check-up assesses for the presence/absence of the asymmetric tonic neck reflex. At this age the reflex:
should have disappeared. This primitive (not protective) reflex should be present at birth and disappear around age 4 months.
A nurse is providing health promotion education to a family of an infant at the family birth center. The nurse knows the parents need more education when they state which response?
"I will switch to whole milk when my baby is around 6 months of age." An infant can be introduced to whole milk at about 1 year of age. At this stage infants' intestinal tracts should be mature enough for whole mile, and they will be less likely to have allergic reactions. Soft food, a drinking cup, and introducing foods one at a time are all correctly stated for developmental age.
A new mother tells the nurse that she a bought car seat for her infant at a garage sale when she was pregnant but that a friend recently told her that she should buy a new one. Which instruction would the nurse give initially?
Check the expiration date on the car seat Initially, the nurse would instruct the client to check the car seat for an expiration date. Expiration dates are now placed on all car seats. The seat identifies when the seat was manufactured. Expiration dates allow for routine updates. If the expiration date had expired, the nurse would instruct to discard the car seat. The other options would be considered if the expiration date was in the future.
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 Infants at age 5 months are in the process of cutting their first teeth, typically the upper or lower central incisors. Symptoms associated with the mouth and feeding are common. Fever and diarrhea are considered signs of illness, not teething.
What feeding practice used by the parents of an 8-month-old should the nurse discourage?
Placing all liquids given the child in a "no spill" sippy cup No-spill sippy cups promote sucking rather than teach cup drinking. Reserve these for times when avoiding spills is a must. The other feeding practices are age appropriate and safe. Soft table and finger foods promote accepting new textures and self-feeding. Reoffering rejected food allows the child to accept it when ready. Including the infant at the family table provides for modeling of eating behaviors and socialization.
The nurse is visiting a mother who has a 3-month-old infant who has been hospitalized for cardiac problems. Which nursing diagnosis should the nurse use to guide care for this family at this time?
Risk for impaired parenting related to hospitalization of infant The diagnosis appropriate for the family whose infant has been hospitalized would be risk for impaired parenting related to hospitalization. There is no evidence to suggest that the mother is not adjusting to parenthood. There is no information about the infant's feeding schedule. There is no information to suggest the mother has a knowledge deficit regarding normal infant growth and development.
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 occurse 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.
A nurse is talking to and making facial expressions at a 9-month-old baby girl during a routine office visit. What is the most advanced milestone of language development that the nurse should expect to see in this child?
The infant says "da-da" when looking at her father By 9 months, an infant usually speaks a first word: "da-da" or "ba-ba." The other answers refer to earlier milestones in language development. In response to a nodding, smiling face, or a friendly tone of voice, a 3-month-old infant will squeal with pleasure or laugh out loud. By 4 months, infants are very "talkative," cooing, babbling, and gurgling when spoken to. At 6 months, infants learn the art of imitating. They may imitate a parent's cough, for example, or say "Oh!" as a way of attracting attention.
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.
The nurse is concerned that a 9-month-old baby is gaining too much weight. What should the nurse instruct the parents to help control the baby's weight gain?
Provide whole-grain cereal for one feeding. A way to prevent obesity is to add a source of fiber such as whole-grain cereal to the infant's diet. This prolongs the stomach-emptying time and helps reduce food intake. Nonfat milk should not be given because it contains little essential fatty acids and will not ensure cell growth. The baby should not be given refined sugars such as diluted gelatin or pudding because this will encourage weight gain.
The mother of a 3-month-old infant expresses concern that her infant's head is misshapen. Which would be the most appropriate question by the nurse?
"Do you use "tummy time" with the infant?" The appropriate question would be for the nurse to assess whether the mother is placing the infant in the prone position during supervised period of time. This allows for the infant to increase head and neck muscle strength and development of rolling over. It also aids in evening out misshapen or flat heads.
Marcy asks the nurse if her 9-month-old son is drinking the recommended amount of breast milk or formula every day. What would the appropriate response be?
"He needs 7 ounces every 6 hours." This response is correct because the recommended amount of milk/breast-milk for an infant 7 to 11 months old is 6 to 8 ounces every 6 to 8 hours. This should be around 32 ounces a day. The other responses do not meet the recommended daily allowance.
A nurse is conducting a class for new mothers about infants and nutrition. One of the women asks, "What is the best nutrition for my 3-month-old infant?" Which response by the nurse would be most appropriate?
"Human milk is the best nutrition for your child" Human milk provides optimal nutritional support for a newborn and has recognized prebiotic and anti-inflammatory effects that enhance biological wellness for the child. Ingestion of human milk is known to aid the newborn's immature immune system. Breastfeeding is the feeding method most encouraged by health care providers today, resulting from the nutritional composition of the milk, the additional immunity it provides the infant in the form of antibodies, and the fact that it has the most easily digestible form of protein. Human milk is readily available, inexpensive, and encourages bonding between the mother and infant. The AAP (2005a) recommends breastfeeding exclusively (no supplemental formulas or baby foods) for approximately the first 6 months and supports continuing breastfeeding after foods are introduced to serve as the child's milk source for the entire first year as long as it is mutually desired by the infant and the mother. Parents should not offer low-iron milks (e.g., cow, goat, soy) to their child until the child is at least 12 months old. Cow's or goat's milk can contributeto anemia because both are deficient in iron. Infants should also never receive low-fat or nonfat milk because these milks do not have the fat, calories, or ironneeded to support the rapid growth and development that occurs at this age.
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." 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 reinforcing teaching with a group of caregivers related to the nutritional needs of the infant. One caregiver asks why the 6-month-old infant needs to have solid foods when breast milk is such a good source of nutrition. What would be the best response by the nurse?
"Milk will not fully provide the child's needs for iron, which is found in solid foods." At about 4 to 6 months of age, the infant's milk consumption alone is not likely to be sufficient to meet caloric, protein, mineral, and vitamin needs. In particular, the infant's iron supply becomes low, and supplements of iron-rich foods are needed. It is also around 4 to 6 months when the infant is able to swallow solids effectively and has the necessary enzymes necessary to digest them. It is true that the child becomes interested in new skills, but this is not the primary rationale for introducing solids. Few parents will understand the "extrusion reflex" so using that term is not effective in teaching. The nurse should, however, describe the reflex to the parents. Breastfeeding does not become painful when the child develops teeth. Many mothers nurse for long after their infants develop teeth.
The mother of an infant questions the nurse about her baby's teething. The nurse provides client education. Which statement by the mother indicates understanding of the information provided?
"The first teeth that will likely appear are the lower incisors." Teeth will begin erupting between 6 and 8 months. Traditionally, the first teeth to erupt will be the lower incisors, followed by the upper incisors. By the age of 12 months, the infant will have between 4 and 8 teeth, if progressing normally.
A new mother shows the nurse that her baby grasps her finger when she touches the baby's palm. How might the nurse respond to this information?
"This is a primitive reflex known as the palmar grasp." Primitive reflexes are subcortical and involve a whole-body response. Selected primitive reflexes present at birth include Moro, root, suck, asymmetric tonic neck, plantar and palmar grasp, step, and Babinski. During the palmar grasp, the infant reflexively grasps when the palm is touched. The plantar grasp occurs when the infant reflexively grasps with the bottom of the foot when pressure is applied to the plantar surface. The root reflex occurs when the infant's cheek is stroked and the infant turns to that side, searching with mouth. The Moro reflex is displayed when with sudden extension of the head, the arms abduct and move upward and the hands form a "C."
A mother takes her 4-month-old to the doctor for a visit. She asks the nurse what type of baby cereal she should buy now that her child is starting solid foods. How should the nurse respond?
"You should buy rice cereal." The rice cereal should be first. The infant should be monitored for food allergies by following the rice cereal with oats, barley, and wheat. Wheat has the highest allergy reaction in infants.
An infant is being introduced to drinking fluids from a cup. The nurse instructs the mother that fruit juice can now be added. Which of the following would the nurse suggest the mother try first? Select all that apply.
Apple White grape juice Juice is introduced when a cup is introduced to an infant. Usually 4-6 ounces of juice is recommended. Juices that have low-acidity like apple and white grape juice are appropriate. These juices may be diluted to half-strength with water. Orange, grapefruit and pineapple juice are to be avoided.
The nurse observes an infant interacting with his parents. What are normal social behavioral developments for this age group? Select all that apply
Around 3 months the infant smiles widely and gurgles when interacting with the caregiver. Around 2 months the infant exhibits a first real smile. Around 3 months the infant will mimic the parent's facial movements, such as sticking out the tongue. Separation anxiety may also start in the last few months of infancy. The infant exhibits a first real smile at age 2 months. By about 3 months of age the infant will start an interaction with a caregiver by smiling widely and possibly gurgling. The 3- to 4-month-old will also mimic the parent's facial movements, such as widening the eyes and sticking out the tongue. Separation anxiety may also start in the last few months of infancy. Around the age of 8 months the infant may develop stranger anxiety. At 6 to 8 months of age the infant may enjoy socially interactive games such as patty-cake and peek-a-boo.
A 6-month-old girl weighs 14.7 pounds (6.7 kg) during a scheduled check-up. Her birth weight was 8 pounds (3.6 kg). What is the priority nursing intervention?
Discussing the child's feeding patterns Assessing the current feeding pattern and daily intake is the priority intervention. Talking about solid food consumption may not be appropriate for this child yet. Discouraging daily fruit juice intake or increasing the number of breastfeedings may not be necessary until the situation is assessed.
The nurse is assessing Julie, a 3-month-old infant. Which developmental milestone would the nurse expect?
Julie can hold her head erect and steady. When an infant matures and grows they move through different developmental milestones. A 3-month-old rolls over from back to side and holds the head erect and steady and begins to replace the reflex grasp with voluntary grasping. Grasping a toy at will occurs at about 6- to 7-months of age. Sitting without support occurs around 6 months. Playing pat-a-cake is characteristic of an 8- to 9-month-old.
During an assessment, the nurse determines that a 3-month-old baby has a Moro reflex. What does this finding indicate to the nurse?
Most 3-month-olds still have a Moro reflex. The Moro reflex will begin to fade at age 5 months and disappear by age 6 months. A Moro reflex at age 9 months or 1 year indicates the need for a neurologic examination.
A new mother, when asked by a nurse, explains that her 4-month-old infant has been nursing regularly every 3 to 4 hours and seems satisfied. However, the mother recently introduced solid food in the form of unbuttered popcorn to the baby as a supplement, to "get her used to eating solid food." She felt that the popcorn would be safe because it is soft on the baby's gums. What should be the primary nursing diagnosis in this situation?
Risk for aspiration related to feeding the infant an inappropriate food Children under about 5 years should not be offered popcorn or peanuts because of the danger of aspiration. This should be the primary nursing diagnosis because aspiration is the greatest danger to the infant in this scenario. Because the infant is receiving all the nutrition she needs from breastfeeding and because unbuttered popcorn is not a high-calorie food, imbalanced nutrition is not really a concern here. There is not a strong indication at this point that the infant is ready for enhanced nutrition, as the breast milk provides all of the nutrients she needs and as she appears to be satisfied after her feedings.
The nurse is visiting a mother who has a 3-month-old infant. Which anticipatory guidance information should the nurse provide to the mother at this time?
The child should be able to turn over onto the back at age 4 months. Infants typically turn over from the front to back at age 4 months. Fear of strangers will not occur until 7 months. The nurse has no way of knowing the infant's temperament to determine that the child will be moody or when the child will expect things to be done a certain way.
A 12-month-old seen at a walk-in clinic weighed 8 pounds 4 ounces (3.75 kg) at birth. Weight now is 20 pounds 8 ounces (9.3 kg). The nurse determines:
The child weighs less than expected for age. Birth weight should triple by 12 months. The child should weigh near 24 pounds 12 ounces (11.25 kg). The child is underweight for age.
In observing an infant who is 6 months of age, which fine motor skill would the infant have most recently attained?
The infant can hold a bottle By the age of 24 weeks, the infant holds a bottle fairly well.
Estimating illness in an infant is difficult. To help an infant's parents do this, which of the following would you instruct them to use?
Use her interest in eating as a good gauge. A healthy infant eats well, voids adequately, and gains weight.
The nurse is examining an 8-month-old girl for appropriate development during a regular check-up. Which observation points to a developmental risk?
Uses only the left hand to grasp Favoring one hand over the other may be a warning sign that proper motor development is not occurring in the other arm or hand. Grasping small objects with the entire hand is common at 8 months and precedes the pincer grasp, which is used about 2 months later. Crawling with stomach down and being unable to pull to standing are abilities that may not occur for another 4 to 8 weeks.
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 Before tooth eruption occurs, parents should clean the infant's gums after feeding with a damp wash cloth. After the first tooth erupts, parents can use a soft bristle tooth brush. Dental hygiene should be part of the infant's everyday care. The American and Canadian Dental Associations recommend the first dental checkup to occur around 1 year of age. Infants should not go to bed with bottles or sippy cups to prevent dental caries.
Anticipatory guidance for an infant for the 4th month should include the fact that the infant will be able to achieve which developmental milestone?
be able to turn over onto the back At four months of age, the infant is able to lift the head and look around. The infant can roll from prone to supine. When being pulled up, the head leads. The 4-month-old infant can make simple vowel sounds, laugh aloud, and vocalize in reponse to voices. A fear of strangers does not occur until the child is older and a 4-month-old infant has not developed emotionally to have "moody" periods and is dependent on parental care.
Which assessment findings if noted in a 4-month-old infant would the nurse recognize as normal growth and development?
holds head up when prone, bears partial weight on legs, reflexes are fading At 4 months of age, the infant should be able to hold the head up when prone and bear partial weight on the legs; newborn reflexes are beginning to fade. The nurse should recognize these changes as normal growth and development.
The nurse pulls the 5-month-old to sitting position from supine and notes head lag. The nurse's response is to:
refer the infant for developmental and/or neurologic evaluation. There should be no head lag by 4 months. Head lag in the 5-month-old may indicate motor or neurologic problems and needs immediate follow-up. All other nursing actions indicate failure to recognize the problem.