Chapter 29: Nursing Care of a Family with an Infant

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 nurse is reviewing the diet of an 8-month-old infant with the mother who reveals she has been using evaporated milk to make the formula. Which additional ingredient should the nurse ensure she is including in the formula?

Iron

The nurse is caring for a 5-week-old infant who is spitting up "all the time." This is the mother's first child. What should be the priority nursing intervention?

Observe the mother while she feeds and burps her infant.

The nurse is caring for an infant with yellow, crusty patches on the scalp. The parent states aggressively washing the scalp with soap and water to remove them, but the infant cries during the process. What will the nurse teach the parent as the best method to remove the scalp crusts?

Soften the crusts by using mineral oil or petroleum jelly prior to removing.

At the 6-month-old well-child visit, the parent is concerned that the child is unsteady and often falls over when sitting. What will the nurse advise the parent about this?

The child's stability will progress to independent sitting over the upcoming months.

The nurse is conducting a physical examination of an 8-month-old infant. Which observation may be cause for concern about the infant's neurologic development?

The infant displays an asymmetric tonic neck reflex (fencing reflex).

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 infant is around 6 months of age."

The nurse is meeting with a group of new mothers of infants and is leading the discussion related to weaning. Which suggestion should the nurse prioritize to this group of mothers concerning weaning their infant?

"It is important to let the infant set the pace for weaning, no matter what age they are."

A client who is breastfeeding asks the nurse if she can give the newborn a pacifier. Which nursing response is most appropriate?

"It is recommended to wait until breastfeeding is well-established before introducing a pacifier."

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."

The nurse takes a call from a concerned mother whose infant received routine immunizations the day before and now has a temperature of 101oF (38.3oC), is fussy, and pulling at the injection site. The mother wants to know what she should do. Which is the best response from the nurse to this mother?

"This is a common reaction. Give your child acetaminophen, cuddle him, and apply a cool compress to the injection site.

A parent expresses concern to the nurse that their 2-week-old infant is crying and grunting when passing stool. What is the nurse's best response to this observation?

"This is normal behavior for infants unless the stool passed is hard and dry."

The nurse is conducting a class for new parents of infants. The nurse determines the session is successful when the parents correctly choose which instruction concerning bathing their infant?

"When I bathe my baby, I shampoo his hair each time as well."

A 2-month-old infant has inconsolable crying, is gassy, and constantly draws the legs up. It has been determined that the infant has colic. Which education will the nurse provide to the parents?

"You can try a pacifier, music, or carrying the baby to help stop crying."

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 nurse is assessing a 1-year-old at the well-child annual visit and notes the child is meeting the growth parameters. After noting the birth weight was 8 pounds (3.6 kg) and length was 20 inches (50.8 cm) long, which measurements reflecting height/weight would the nurse expect to document for this visit?

24 pounds (10.8 kg) and 30 inches (75 cm)

A group of nursing students are preparing a presentation illustrating basic safety measures which can be utilized for infants. Which measure(s) should the students include in their presentation? Select all that apply.

Car seats should be placed in back seats. Toilet seats should be closed. Crib and playpen bars should be no more than 2 3/8 inches apart.

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

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

A nurse is collecting weight on a 6-month-old infant. The weight was 14 lbs 3 oz. The mother states that the infant's birth weight was 8 lbs 8 oz. What is the nurse's assessment of this data?

The weight is too little for age.

A first-time mother calls the pediatrician's office to ask the nurse about her baby's tooth eruption. The baby is 8 months old and still does not have any teeth. What information can the nurse share with this mother that would correctly respond to her anxiety about her baby's dentition?

Tooth eruption is often genetically based, with some families having babies with early tooth eruption, while others have late tooth eruption.

The nurse is watching a group of infants playing in an infant room at day care. When analyzing the developmental characteristics exhibited, which infant would the nurse identify as being approximately 3 months of age?

infant laying prone with a colorful toy in front

A staff nurse is talking about Piaget's theory with a nursing student. Infants are in the sensorimotor stage of cognitive development during which object permanence is mastered. An example of an infant displaying this ability is:

looking for a toy in her crib at the last place she saw it.

In providing anticipatory guidance related to choking and suffocation hazards for infants, what should the nurse include in the teaching? Select all that apply.

propping a bottle raw carrots plastic bags crib slats 3.5 in (9 cm) apart

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.

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

A 12-month-old seen at a walk-in clinic weighed 8 pounds 4 ounces (3750 g) at birth. Weight now is 20 pounds 8 ounces (9300 g). The nurse determines:

the child weighs less than expected for age.

The nurse is conducting an educational session at a local community health fair illustrating the various reflexes which are normal in a newborn and how they change as the infant grows and matures. The nurse determines more education is necessary after a member of the audience points out which finding as an expected occurrence?

an extrusion reflux at 9 months of 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."

The nurse is assessing a 6-month-old infant in the clinic. Which characteristic represents normal language development for this age?

Babbling

The nurse is preparing to teach a class to a group of young parents with infants the basics of introducing solid foods into the diet. Which factor about the food should the nurse point out the infants respond to best when introducing solid foods into the diet?

bland