Chapter 3, Growth and Development of the Newborn and Infant

What action shows an example of Erik Erikson's developmental task for the infant?

The infant cries and the caregiver picks the child up. Explanation: 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 in a community clinic is assessing a 2-month-old infant. The parent asks if the infant is developing normally. The nurse refers to which finding as suggestive of normal development in infants from birth to 2 months of age?

The infant raises head and chest while on stomach. Explanation: Infants have gained some neck control and can independently raise head and chest by 2 months of age. Transferring objects from one hand to another is expected at 7 months of age. Laughing aloud and responding to his or her name is expected between 4 to 5 months of age. Sitting in the tripod position is not expected until 6 months of age

A mother of a 10-month-old states to the nurse, "I brush my child's teeth every day with flavored kids' toothpaste." Which is the most appropriate response by the nurse?

"Toothpaste is not necessary; it is the scrubbing that is required." Explanation: Toothpaste for infants is not required. The important health technique is the removing of plaque, and that is accomplished through scrubbing of the teeth.

The parents of an 8-month-old infant voice concern to the nurse that their infant is not developing motor skills as they should. What question should the nurse ask to help determine if their fears are warranted?

"Does your infant move a toy back and forth from one hand to the other when you give it to them?" Explanation: Transferring an object from one hand to the other is expected at 7 months of age, so this ability would be expected of an 8-month-old. The other questions relate to abilities that are not expected until later months. Questioning the parents about these skills would not help in determining if the infant has the motor skill developmental level that should be expected

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." Explanation: It is recommended to wait to introduce a pacifier once breastfeeding is well-established, which can take about 1 month. This is to limit nipple confusion and promote an adequate milk supply. Stating other people have done this does not provide education to the client, nor does it address this specific client's situation. While the decision is up to the newborn's parents, this response does not address the client's concern. Requesting a lactation consultant come does not address the client at this moment. The nurse can provide education now, and also request the consultant for follow-up information

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 is the best response by the nurse?

"Milk will not fully provide the infant's needs for iron, which is found in solid foods." Explanation: 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 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 parents breastfeed for long after their infants develop teeth

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." Explanation: The nurse should reinforce that stuffed animals, blankets, pillows, and soft mattresses are suffocation hazards for infants.

The mother of a 6-week-old infant reports she doesn't know if her child recognizes her face yet. What response by the nurse is most appropriate?

"Since about 4 weeks of age your child has been able to recognize those who are around him often." Explanation: At 1 month of age the infant can recognize by sight the people he or she knows best. Telling the child's mother that this will come with time is not correct as this developmental milestone has already occurred. Telling her not to worry minimizes her questions and concerns

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." Explanation: 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.

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?" Explanation: 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 parents of a 4-day-old infant report concern about his weight loss. What is the best response by the nurse?

"With appropriate nutrition weight gain will commence with a return to the birth weight within 2 weeks." Explanation: The question asks for the best response which typically informs or instructs the client on a situation in which they are concerned. The average newborn weighs 7 lb 8 oz (3,400 g) at birth. Newborns lose up to 10% of their body weight over the first week of life. The average newborn then gains about 30 g per day and regains his or her birth weight by 10 to 14 days of age. 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.

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) Explanation: By 1 year of age, the infant should have tripled his or her birth weight and grown 10 to 12 inches (25 to 30 cm). If this infant was 8 pounds (3.6 kg) at birth, at 1 year, this child should weigh 24 pounds (8 x 3 = 24) and grown to 30 to 32 inches (20 + 10 to 12 = 30 to 32 inches). Most of the growing occurs during the first 6 months with the infant's birth weight doubling and height increasing about 6 inches (15 cm). Growth slows slightly during the second 6 months but is still rapid.

The infant measures 21.5 in (54.6 cm) at birth. If the infant is following a normal pattern of growth, what would be an expected height for the infant at the age of 6 months?

27.5 in (70 cm) Explanation: Infants gain about 0.5 to 1 in (1.25 to 2.5 cm) in length for each of the first 6 months of life. Therefore, a 21.5-in (54.6-cm) infant adding 6 in (15 cm) of growth would be 27.5 in (70 cm). Infants grow the fastest during the first 6 months of life and slow down the second 6 months. By 12 months of age, the infant's length has increased by 50%, making this infant 32 in (81 cm) at 1 year old

The postpartum nurse observes new mothers as they put their newborns in the bassinet to sleep. Which actions by the new mothers require further instruction from the nurse? Select all that apply. A) A mother places her newborn on its side after falling asleep. B) A mother states all of her children like sleeping on their abdomen and this newborn likes it too. C) A mother places the baby comforter her grandmother made over the newborn's body. D) A mother tells her husband to be sure to place the newborn on his back when putting the baby in the bassinet. E) A mother states her baby looks too warm, so she is moving the bassinet in front of the air conditioner to cool him off.

A) A mother places her newborn on its side after falling asleep. B) A mother states all of her children like sleeping on their abdomen and this newborn likes it too. C) A mother places the baby comforter her grandmother made over the newborn's body. E) A mother states her baby looks too warm, so she is moving the bassinet in front of the air conditioner to cool him off.

The parent of a 6-month-old infant asks the nurse for advice about his son's thumb sucking. What would be the nurse's best response to this parent? A)Thumb sucking is a healthy self-comforting activity." B)Thumb sucking leads to the need for orthodontic braces." C)Caregivers should pay special attention to the thumb sucking to stop it." D)Thumb sucking should be replaced with the use of a pacifier."

ANS:A Feedback: Thumb sucking is a healthy self-comforting activity. Infants who suck their thumbs or pacifiers often are better able to soothe themselves than those who do not. Studies have not shown that sucking either thumbs or pacifiers leads to the need for orthodontic braces unless the sucking continues well beyond the early school-age period. The infant who has become attached to thumb sucking should not have additional attention drawn to the issue, as that may prolong thumb sucking. Pacifiers should not be used to replace thumb sucking as this habit will also need to be discouraged as the child grows.

At which age would the nurse expect to find the beginning of object permanence? A)1 month B)6 months C)9 months D)12 months

ANS:B Feedback:Object permanence begins to develop between 4 and 7 months of age and is solidified by approximately age 8 months. By age 12 months, the infant knows he or she is separate from the parent or caregiver.

The nurse is completing a developmental assessment on a 6-month-old infant. Which findings indicate the need for additional follow-up? Select all that apply. A) The infant babbles. B) The infant does not pay attention to noises behind him. C) The infant has frequent episodes of crossed eyes. D) The infant seems disinterested in the surrounding environment. E) The infant is unable string together 2 word sentences.

B) The infant does not pay attention to noises behind him. C) The infant has frequent episodes of crossed eyes. D) The infant seems disinterested in the surrounding environment. Explanation: Warning signs that may indicate problems with sensory development include the following: young infant does not respond to loud noises; child does not focus on a near object; infant does not start to make sounds or babble by 4 months of age; infant does not turn to locate sound at age 4 months; infant crosses eyes most of the time at age 6 months. Language development at this stage of development does not include stringing together 2-word sentences.

When performing neurological reflexes on the infant, which primitive reflex will be present longest?

Babinski Explanation: 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. Except for the Babinski, which disappears around 1 year of age, these primitive reflexes diminish over the first few months of life, giving way to protective reflexes.

The nurse is providing client education to the parent about bathing the infant. What would be important to instruct the parent?

Bath time provides an opportunity for play Explanation: The work of children is play. Play provides a natural way for the infant to learn. In early infancy infants prefer their parents rather than toys. Parents can talk and sing to infants during feeding, bathing, and changing diapers. Infants do not need a daily bath as long as the diaper area is washed with diaper changes. Soap is actually drying to an infant's skin. Washing the hair with soap can help remove excess oil.

During the first visit to the pediatrician's practice the nurse is performing an admission interview and assessment of a 4-week-old infant. The mother states, "I am sure my baby girl knows my smell because she is much more settled in my arms rather than my mother's arms when she is upset." What is an appropriate response by the nurse? A)"Babies really can't tell the difference between people at that age." B)"Maybe she just knows your voice better than your mother's." C)"You may be right, since infants can sense their mother's smell as early as 7 days old." D) "I'm not sure a 4-week-old infant can tell their mother from another woman's smell."

C)"You may be right, since infants can sense their mother's smell as early as 7 days old." Explanation: The sense of smell develops rapidly: the 7-day-old infant can differentiate the smell of his or her mother's breast milk from that of another woman and will preferentially turn toward the mother's smell.

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 Explanation: Infants who are fed home-prepared formulas (based on evaporated milk) need supplemental vitamin C and iron. Evaporated milk has adequate amounts of vitamin D, which is unaffected by heat used in the preparation of formula. Calcium and vitamin E would not be a concern in this infant's formula

An infant is breastfed. When assessing the stools, which findings would be typical?

Less constipation than bottle-fed infants Explanation: The first stool of the infant is meconium. It is the result of digestion of amniotic fluid and it is black-green color and sticky. Following that, in 1 to 2 days the infant's stools change to a yellowish-tan color. The stools of breastfed infants tend to be yellow-tan. They are looser in texture and appear "seedy." The stool of a bottle-fed baby has the consistency of peanut butter. The stools of breastfed babies generally have no odor since all milk is digested. Some babies will have a bowel movement with every feeding but it is small. Bottle-fed babies have less stools each day but they are larger and more likely to have an associated odor.

The nurse is assessing the newborn. Which would the nurse assess to be an abnormal finding?

Natal teeth noted in the mouth that are loose Explanation: The presence of 1 or 2 teeth at birth (natal teeth) is a finding that may be benign or may point to other congenital abnormalities. The neck should be short, thick and mobile. The gluteal folds should be symmetrical. It is normal for the newborn to startle to loud sounds

Which activity will the nurse encourage new parents to complete in order to assist their infant in accomplishing Erikson's developmental task for the first year of life?

Respond promptly when the infant cries. Explanation: The developmental task of the infant year, according to Erikson, is to gain a sense of trust. This can be accomplished by promptly meeting the infant's needs during the first year of life. If the infant does not learn to trust, mistrust will develop. Praising will help meet the future developmental tasks of the child. Reading books and appropriately enunciating words will aid in the infant's language development.

A nurse is educating a client being discharged with her newborn baby. What is the highest priority item that must be included in the teaching plan?

Restrain the baby in a car seat. Explanation: The client should restrain the baby in a car seat when driving. Infants are especially vulnerable to injuries resulting from falls from changing tables or being unrestrained in automobiles. Locking the cabinets and giving warm bottles of formula to the baby are secondary teachings

The nurse is teaching healthy eating habits to the parents of a 7-month-old girl. Which recommendation is the most valuable advice?

Serve new foods several times. Explanation: When introducing a new food to an infant, it may take multiple attempts before the child will accept it. Parents must demonstrate patience. Letting the child eat only the foods she prefers, forcing her to eat foods she does not want, or actively urging the child to eat new foods can negatively affect eating patterns.

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

Sitting without support Explanation: 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.

At what age would it be okay to introduce carrots to an infant's diet?

Solid food can be introduced at 4 to 6 months of age. Explanation: The tongue extrusion reflex is present until the infant is 4 to 6 months of age. After this reflex disappears then solid food may be introduced. The infant's ability to swallow solid foods is not completely functional until this age nor are the enzymes present which are needed to process foods. The infant must be ready to handle spoon-feeding. By 7 months onward, the baby should be eating solid foods regularly and drinking from a cup in addition to breast or bottle feeds.

The nurse is performing an assessment on a 8-month-old infant. The infant's medical history notes that he was born at 32 weeks' gestation. The infant is progressing normally. At what adjusted age should the nurse expect the infant's developmental accomplishments?

The infant will most likely present with developmental skills consistent with a 6-month-old infant. Explanation: When assessing the growth and development of a premature infant, the nurse will use the infant's adjusted age to determine expected outcomes. To determine adjusted age, the nurse subtracts the number of weeks that the infant was premature from the infant's chronological age. The infant who was born at 32 weeks' gestation was 8 weeks (or 2 months) premature. To determine the adjusted age, the nurse subtracts 2 months from the chronological age of 8 months: 6 months.

The student nurse is reviewing the chart of a newborn. The document indicates the newborn is in the quiet alert state. Which is the best description of this sleep phase?

The newborn's eyes are open and no body movements are noted. Explanation: The normal newborn moves through 6 stages of consciousness. The quite alert state is when the infant's eyes are open but the body is calm. Open eyes accompanied by body movements is characteristic of the active alert state

The parent of a 1-month-old infant voices concern about the infant's respirations. The parent states the respirations are rapid and irregular. Which information should the nurse provide?

The respirations of a 1-month-old infant are normally irregular and periodically pause. Explanation: The normal respiratory rate for a 1-month-old infant is 30 to 60 breaths per minute. By 1 year of age, the rate will be 20 to 30 breaths per minute. The respiratory patterns of the 1-month-old infant are irregular. There may normally be periodic pauses in the rhythm

The nurse is assessing the sleeping practices of the parents of a 4-month-old girl who wakes repeatedly during the night. Which parent comment might reveal a cause for the night waking?

They put her to bed when she falls asleep. Explanation: If the parents are keeping the child up until she falls asleep, they are not creating a bedtime routine for her. Infants need a transition to sleep at this age. If the parents are singing to her before she goes to bed, if she has a regular, scheduled bedtime, and if they check on her safety when she wakes at night, then lie her down and leave, they are using good sleep practices.

The nurse is caring for the family with a 2-month-old boy with colic. The mother reports feeling very stressed by the baby's constant crying. Which intervention would provide the most help in the short term?

Urging the baby's mother to take time for herself away from the child. Explanation: Urging the parents to get time away from the child would be most helpful in the short term, particularly if the parents are stressed. Educating the parents about when colic stops would help them see an end to the stress. Observing how the parents respond to the child helps to determine if the parent/ child relationship was altered. Assessing the parents' care and feeding skills may identify other causes for the crying.

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 Explanation: 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 Explanation: 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 response to voices. A fear of strangers does not occur until the child is older; a 4-month-old infant has not developed emotionally to have "moody" periods and is dependent on parental care

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. Explanation: Looking for the toy where it was last seen indicates object permanence. The infant knows the object still exists even though she cannot see it. All the rest of the infant's behaviors show use of her senses and motor activity but do not illustrate object permanence.

The nurse is assessing the oral cavity of a 6-month-old child. When palpating the location in which the first primary teeth erupt, which location is being assessed?

lower central gumline Explanation: The lower central incisors are usually the first to appear, followed by the upper central incisors

A 5-month-old infant being assessed was born at 32 weeks. The nurse doing the well-child check-up should compare the baby to what norms?

the development of a 3-month-old Explanation: The infant was born 8 weeks early. Two months are subtracted from the present age of 5 months. Both growth and development should be assessed using 3-month norms

A nurse is reviewing the health records of several 4-month-old infants who were seen in the pediatric office today. Which infant behavior will require referral for further evaluation of growth and development?

unable to support their head Explanation: An infant at 4 months of age who cannot support their head should be referred for evaluation. A 4-month-old infant should be able to reach for objects of interest and should be able to roll from a prone to a supine position. A 4-month-old infant is not expected to be able to sit alone without support.

A 9-month-old has been brought to the clinic for a well-child visit. The mother reports her son was born 6 weeks prematurely. During the data collection, the child's mother reports her son seems to be a few months "behind" what she recalls from her older children. What is the best response by the nurse?

"Delays are normal when a child is premature." Explanation: When infants are born prematurely delays may be noted. When assessing the growth and development of a premature infant, use the infant's adjusted age to determine expected outcomes. To determine adjusted age, subtract the number of weeks that the infant was premature from the infant's chronological age. Plot growth parameters and assess developmental milestones based on adjusted age. Delays will not necessarily be resolved by the age of 6 months. While the mother should talk with the physician about concerns, this is not the best initial response by the nurse

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 Explanation: 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 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 Explanation: 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 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. Explanation: This primitive (not protective) reflex should be present at birth and disappear around age 4 months.

A parent calls the clinic nurse asking for a recommendation on comfort measures for the infant who is teething. What recommendation will the nurse make?

teething ring Explanation: The nurse will recommend a teething ring that can be refrigerated. The parent also may rub the infant's gums with a cold, not warm, compress. Hard candy and ice chips pose a choking hazard for the infant.

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. Explanation: Birth weight should triple by 12 months. The child should weigh near 24 pounds 12 ounces (11250 g). The child is underweight for age

The nurse is caring for a parent following the birth of the newborn. The new parent asks the nurse, "When is the best time for me to start bonding with my baby?" Which response by the nurse is appropriate?

"You should interact with your newborn when the eyes are open wide and bright." Explanation: A newborn's neurological development includes 6 states of consciousness. The best time for a family to interact with a newborn is when the newborn is in the quiet or active alert stage. The quiet alert state is when the body is calm and the eyes are wide open. The active alert state is when the eyes are wide open and there are body movements. Examples of this are minimal body activity, regular respirations, face with shiny look, eyes wide and bright, and paying attention to stimuli. When the newborn is crying it is very difficult to get the newborn's attention. The newborn needs immediate needs met at this time such as feeding, repositioning, or a diaper change. When the newborn is in a drowsy state, trying to interact only causes frustration for the newborn as sleep is interrupted.

The parent of 1-week-old infant voices concerns about the infant's weight loss since birth. At birth the infant weighed 7 lb (3.2 kg); the infant currently weighs 6 lb 5 oz (2.9 kg). Which response by the nurse is most appropriate?

"Your infant's weight loss is within the expected range." Explanation: The normal newborn may lose up to 10% of birth weight. This infant has lost 9.1%. This degree of weight loss will likely not require hospitalization. Expressing to the parent that the infant may be hospitalized is rash and will most likely not occur.

A parent asks the nurse if the 2-month-old infant can have bananas yet. The nurse would respond and educate the parent on the nutrition stages of infants by which response?

"You can try bananas 2 or 3 months from now." Explanation: The nurse will educate the parent to wait 2 to 3 months, because solid foods are not recommended for infants at 2 months of age. The age of 4 to 6 months is when it is recommended to introduce solid foods. In 1 month, the infant will be only 3 month of age. The other responses will not help the parent determine the appropriate answer

The student nurse is reviewing the records of a pediatric client. Which statement about the client's progress indicates the need for further instruction?

"Maturation refers to the child's increases in body size." Explanation: Growth refers to an increase in physical size. Development is the sequential process by which infants and children gain various skills and functions. Heredity influences growth and development by determining the child's potential, while environment contributes to the degree of achievement. Maturation refers to an increase in functionality of various body systems or developmental skills

The nurse enters a client's room to find the new mother crying softly. The client states, "I had my heart set on breastfeeding but my infant was born with a cleft lip. My dreams of breastfeeding are destroyed." Which response by the nurse is appropriate?

"You may still breastfeed your infant. I will show you appropriate techniques to use." Explanation: The nurse should be therapeutic and reassure the mother that breastfeeding may still be an option. Infants with cleft lips may still successfully breastfeed once appropriate techniques are learned and implemented. A supplemental nursing system is used to provide supplemental milk to breastfeeding babies. Telling the client to speak with a lactation consultant does not address the client's current concern

A 6-month-old girl weighs 14.7 lb during a scheduled check-up. Her birth weight was 8 lb. What is the priority nursing intervention? A)Talking about solid food consumption B)Discouraging daily fruit juice intake C)Increasing the number of breastfeedings D)Discussing the child's feeding patterns

ANS: D Feedback: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.

A new mother reports that she is exhausted and that the little sleep she gets is determined by her baby. Which suggestion should the nurse prioritize to help the mother establish healthy sleeping patterns in her infant?

Use the crib for sleeping only, not for play activities. Explanation: A consistent bedtime routine is usually helpful in establishing healthy sleeping patterns and in preventing sleep problems. Using the crib for sleeping only helps the child associate the bed with sleep. Depriving the baby of sleep during the afternoon or evening will make the baby over-tired and less able to establish a healthy sleeping pattern. While letting a baby cry for a while is acceptable, this does not promote consistency in the baby's sleeping pattern

The nurse is assessing the oral cavity of a 4-month-old infant. Which finding is consistent with a child of this age?

no teeth Explanation: Normally infants are not born with teeth. Occasionally there are one or more teeth at birth. These are termed natal teeth and are often associated with anomalies. The first primary teeth typically erupt between the ages of 6 and 8 months.

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. Explanation: 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

A parent takes the 4-month-old infant to the health care provider. The parent asks what type of baby cereal to provide now that the infant is starting solid foods. How should the nurse respond?

"You should buy rice cereal." Explanation: 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.

A first-time mother, who is breastfeeding, phones the clinic nurse because she is concerned about her 3-month-old infant's stools. Which statement by the mother would alert the nurse to contact the health care provider?

"The stools are small and hard." Explanation: The breastfed infant has stools that appear yellow and seedy. Consistency of stool is more important than frequency. Small, hard stools are a concern, and the infant should be evaluated for gastrointestinal issues. The nurse will contact health care provider. It is normal for infants to appear to have difficulty with bowel movements because the gastrointestinal system is still immature. It is common for infants to go several days without having a bowel movement

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) Explanation: 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 infant weighs 7 lb 4 oz (3300 g) at birth. If the infant is following a normal pattern of growth, what would be the expected weight for this child at the age of 12 months?

21 lb 12 oz (9.9 kg) Explanation: The average weight of a newborn is 7.5 lb (3400 g). The infant gains about 30 g each day. By 1 year of age, the infant has tripled the birth weight and has grown 10 to 12 in (25 to 30 cm). 7.25 lb × 3 = 21.75 lb or 21 lb 12 oz (9.9 kg)

The nurse is providing a nutrition workshop for the parents of infants. The nurse understands that further instruction is required when hearing which comments from the parents? Select all that apply. A)"Food is so expensive. I can't afford for my child to leave any food on the plate." B)"I have tried at least 10 times with every green vegetable and I can't get my son to like them." C)"I try to eat healthy in front of my daughter so she will hopefully pick up good eating habits." D)"I let my child eat whatever he wants right now so that we don't argue about food. E) Hopefully he will like healthy foods when he grows up." F)"I plan on encouraging my son to cook with me when he is old enough so that he will enjoy a variety of foods and learn how to cook too."

A)"Food is so expensive. I can't afford for my child to leave any food on the plate." B)"I have tried at least 10 times with every green vegetable and I can't get my son to like them." D)"I let my child eat whatever he wants right now so that we don't argue about food. Hopefully he will like healthy foods when he grows up." Explanation: Encouraging children to eat everything on their plate can lead to overeating and obesity. Children may need to be exposed to new food at least 20 times before determining if they like it or not. Letting a child eat whatever he wants does not lead to good choices as the child matures.

The nurse is educating the parents of a newborn prior to discharge home. The parents demonstrate teaching was successful when making which statement(s)? Select all that apply. A)"I will not be concerned if my newborn has stools that begin to have a yellowish color to them." B)"We should get some rest in about 1 month when the newborn starts sleeping through the night." C)"I plan to add a little rice cereal to my breast milk so my newborn will sleep longer at night." D)"I understand it is normal for newborns to lose 5% to 10% of their bodyweight after birth." E) "My newborn can see up-close things, like our faces, better than things at a distance."

A)"I will not be concerned if my newborn has stools that begin to have a yellowish color to them." D)"I understand it is normal for newborns to lose 5% to 10% of their bodyweight after birth." E) "My newborn can see up-close things, like our faces, better than things at a distance." Explanation: Newborn stools will become yellowish in color after the first few days of life. Newborns typically lose 5% to 10% of their birthweight the first few days of life, and begin to gain weight after this period. Newborns have better up-close vision and begin to recognize human faces during their newborn stage. Most infants will not sleep through the night until about 3 months of age. There is no evidence that rice cereal keeps a newborn from waking and the practice of feeding rice cereal to newborns is discouraged by physicians as the newborn needs formula or breast milk specifically.

A nurse in a pediatrician's office is educating a parent of a 2-month-old infant about developmental milestones. Drag words from the choices below to fill in each blank in the following sentence. The parent requires further education when the parent states. A)"My infant should be able to sit on their own by 3 months.", B)"At 6 months, my baby should be able to feed themselves.". C)"My infant should be able to crawl by 9 months." D) I will be able to play games like peek-a-boo with my infant when they are 4 months old E) My infant should be able to support themselves on elbows and wrists when lying on stomach

A)"My infant should be able to sit on their own by 3 months.", B)"At 6 months, my baby should be able to feed themselves.". D) I will be able to play games like peek-a-boo with my infant when they are 4 months old

The nurse is educating the parents of a newborn prior to discharge home. The parents demonstrate teaching was successful when making which statement(s)? Select all that apply. A)I will not be concerned if my newborn has stools that begin to have a yellowish color to them." B)We should get some rest in about 1 month when the newborn starts sleeping through the night." C)I plan to add a little rice cereal to my breast milk so my newborn will sleep longer at night." D)I understand it is normal for newborns to lose 5% to 10% of their bodyweight after birth." E)My newborn can see up-close things, like our faces, better than things at a distance."

A)I will not be concerned if my newborn has stools that begin to have a yellowish color to them." D)I understand it is normal for newborns to lose 5% to 10% of their body weight after birth." E)My newborn can see up-close things, like our faces, better than things at a distance."

The nurse is assessing the developmental milestones of an infant. The infant was born 8 weeks ago and was 4 weeks premature. The nurse anticipates that the infant will be meeting milestones for what age of child? Record your answer in weeks.

ANS: 4 Feedback:To determine adjusted age, subtract the number of weeks that the infant was premature (4 weeks) from the infant's chronologic age (8 weeks).

A new mother expresses concern to the nurse that her baby is crying and grunting when passing stool. What is the nurse's best response to this observation? A)This is normal behavior for infants unless the stool passed is hard and dry." B)This is normal behavior for infants due to the immaturity of the gastrointestinal system." C)This indicates a blockage in the intestine and must be reported to the healthcare provider." D)This is normal behavior for infants unless the stool passed is black or green.

ANS: A Feedback:Due to the immaturity of the gastrointestinal system, newborns and young infants often grunt, strain, or cry while attempting to have a bowel movement. This is not of concern unless the stool is hard and dry. Stool color and texture may change depending on the foods that the infant is ingesting. Iron supplements may cause the stool to appear black or very dark green.

The nurse in a community clinic is caring for a 6-month-old boy and his mother. Which intervention is priority to promote adequate growth? A)Monitoring the child's weight and height B)Encouraging a more frequent feeding schedule C)Assessing the child's current feeding pattern D)Recommending higher-calorie solid foods

ANS: A Feedback:Monitoring the child's weight and height is the priority intervention to promote adequate growth. Encouraging a more frequent feeding schedule, assessing the child's current feeding pattern, and recommending higher-calorie solid foods are interventions when the nursing diagnosis is that nutrition level does not meet body requirements.

The nurse is caring for a 7-month-old girl during a well-child visit. Which intervention is most appropriate for this child? A)Discussing the type of sippy cup to use B)Advising about increased caloric needs C)Explaining how to prepare table meats D)Describing the tongue extrusion reflex

ANS: A Feedback:The cup may be introduced at 6 to 8 months of age. Old-fashioned sippy cups are preferred compared to the new style. The nurse would not advise about increased caloric needs as caloric needs drop at this age. Transition to table meat will not take place until age 10 to 12 months. Tongue extrusion reflex has disappeared at age 4 to 6 months.

The nurse is providing anticipatory guidance to the mother of a 9-month-old girl during a well-baby visit. Which topic would be most appropriate? A)Advising how to create a toddler-safe home B)Warning about small objects left on the floor C)Cautioning about putting the baby in a walker D)Telling about safety procedures during baths

ANS: A Feedback:The most appropriate topic for this mother would be advising her on how to create a toddler-safe home. The child will very soon be pulling herself up to standing and cruising the house. This will give her access to areas yet unexplored. Warning about small objects left on the floor, telling about safety procedures during baths, and cautioning about using baby walkers would no longer be anticipatory guidance as the child has passed these stages.

The nurse is teaching a new mother about the drastic growth and developmental changes her infant will experience in the first year of life. Which statement describes a developmental milestone occurring in infancy? A). By 6 months of age, the infant's brain weighs half that of the adult brain; at age 12 months, the brain weighs 2.5 times what it did at birth. B)Most infants triple their birth weight by 4 to 6 months of age and quadruple their birth weight by the time they are 1 year old. C)The head circumference increases rapidly during the first 6 months: the average increase is about 1 in per month. D)The heart triples in size over the first year of life; the average pulse rate decreases from 120 to 140 in the newborn to about 100 in the 1-year-old.

ANS: A Feedback:By 6 months of age, the infant's brain weighs half that of the adult brain; at age 12 months, the brain weighs 2.5 times what it did at birth. 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. The head circumference increases rapidly during the first 6 months: the average increase is about 0.6 in (1.5 cm) per month. The heart doubles in size over the first year of life. As the cardiovascular system matures, the average pulse rate decreases from 120 to 140 in the newborn to about 100 in the 1-year-old.

A new mother tells the nurse that she is having difficulty breastfeeding her baby. When observing the mother, which actions prompt the nurse to provide teaching about proper breastfeeding techniques? Select all that apply. A)The mother carefully washes her breasts prior to feeding the infant. B)The mother feeds the infant every hour. C)The mother supplements feedings with water. D)The mother holds her breast in the "C" position. E)The mother strokes the nipple against the infant's face.

ANS: A, B, C Feedback:The mother should wash her hands prior to breastfeeding the infant. There is no need to wash the breasts in most circumstances. The best time to feed the infant is on demand rather than hourly, and there is no need to supplement breastfeeding with water. The "C" position and stroking the nipple against the infant's face promote effective breastfeeding.

The nurse is assessing the infants in the nursery for the six stages of consciousness. The nurse becomes concerned when assessing which infants? Select all that apply. A)An infant rapidly moves from deep sleep to crying. B)An infant moves from active alert state to drowsiness. C)An infant progresses slowly from deep sleep to light sleep. D)An infant frequently skips the quiet alert state during the six stages of consciousness. E) An infant ends the stages of consciousness with crying.

ANS: A, B, D Feedback:The nurse becomes concerned if the infant does not move slowly through six states of consciousness, which begin with deep sleep. The infant should then progress as follows: light sleep, drowsiness, quiet alert state, active alert state, and finally crying. States are not normally skipped.

The nurse caring for newborns knows that infants exhibit phenomenal increases in their gross motor skills over the first 12 months of life. Which statements accurately describe the typical infant's achievement of these milestones? Select all that apply. A)At 1 month, the infant lifts and turns the head to the side in the prone position. B)At 2 months, the infant rolls from supine to prone to back again. C)At 6 months, the infant pulls to stand up. D)At 7 months, the infant sits alone with some use of hands for support. E)At 9 months, the infant crawls with the abdomen off the floor. F)At 12 months, the infant walks independently.

ANS: A, D, E, F Feedback:At 1 month, the infant lifts and turns the head to the side in the prone position. At 7 months, the infant sits alone with some use of hands for support. At 9 months, the infant crawls with the abdomen off the floor. At 12 months, the infant walks independently. At 4 months, the infant lifts the head and lTooEkSsTarBoAunNdK. ASEt 1L0LmEoRn.thCs,OthMe infant pulls to stand up.

3. The nurse is assessing the respiratory system of a newborn. Which anatomic differences place the infant at risk for respiratory compromise? Select all that apply. A)The nasal passages are narrower. B)The trachea and chest wall are less compliant. C)The bronchi and bronchioles are shorter and wider. D)The larynx is more funnel-shaped. E)The tongue is smaller. F)There are significantly fewer alveoli.

ANS: A, D, F Feedback:In comparison with the adult, in the infant, the nasal passages are narrower, the trachea and chest wall are more compliant, the bronchi and bronchioles are shorter and narrower, the larynx is more funnel shaped, the tongue is larger, and there are significantly fewer alveoli. These anatomic differences place the infant at higher risk for respiratory compromise. The respiratory system does not reach adult levels of maturity until about 7 years of age.

Which reflex, if found in a 4-month-old infant, would cause the nurse to be concerned? A)Plantar grasp B)Step C)Babinski D)Neck righting

ANS: B Feedback:Appropriate appearance and disappearance of primitive reflexes, along with the development of protective reflexes, indicates a healthy neurologic system. The step reflex is a primitive reflex that appears at birth and disappears at 4 to 8 weeks of age. The plantar grasp reflex is a primitive reflex that appears at birth and disappears at about the age of 9 months. The Babinski reflex is a primitive reflex that appears at birth and disappears around the age of 12 months. The neck righting reflex is a protective reflex that appears around the age of 4 to 6 months and persists.

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? A)I'll start with baby oatmeal cereal mixed with low-fat milk." B)The cereal should be a fairly thin consistency at first." C)I can puree the meat that we are eating to give to my baby." D)Once he gets used to the cereal, then we'll try giving him a cup."

ANS: B Feedback: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.

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? A)This is a primitive reflex known as the plantar grasp." B)This is a primitive reflex known as the palmar grasp." C)This is a protective reflex is known as rooting D)This is a protective reflex known as the Moro reflex."

ANS: B Feedback: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."

The nurse is counseling the mother of a newborn who is concerned about her baby's constant crying. What teaching would be appropriate for this mother? A)Carrying the baby may increase the length of crying. B)Reducing stimulation may decrease the length of crying. C)Using vibration, white noise, or swaddling may increase crying. D)Using a swing or car ride may increase the incidence of crying episodes.

ANS: B Feedback:Prolonged crying leads to increased stress among caregivers. Reducing stimulation may decrease the length of crying, and carrying the infant more may be helpful. Some infants respond to the motion of an infant swing or a car ride. Vibration, white noise, or swaddling may also help to decrease fussing in some infants. Parents should try one intervention at a time, taking care not to stimulate the infant excessively in the process of searching for solutions.

The nurse is assessing a 4-month-old boy during a scheduled visit. Which findings might suggest a developmental problem? A)The child does not babble. B)The child does not vocally respond to voices. C)The child never squeals or yells. D)The child does not say dada or mama.

ANS: B Feedback:The fact that the child does not vocally respond to voices might suggest a developmental problem. At 4 to 5 months of age, most children are making simple vowel sounds, laughing aloud, doing raspberries, and vocalizing in response to voices. The child is too young to babble, squeal, yell, or say dada or mama.

The nurse is caring for a 4-week-old girl and her mother. Which is the most appropriate subject for anticipatory guidance? A)Promoting the digestibility of breast milk B)Telling how and when to introduce rice cereal C)Describing root reflex and latching on D)Advising how to choose a good formula

ANS: B Feedback: Telling the mother how to introduce rice cereal is the most appropriate subject for anticipatory guidance. Since this mother is already breast- or bottle-feeding her baby, educating her about these subjects would not inform her about what to expect in the next phase of development.

The nurse observes an infant interacting with his parents. What are normal social behavioral developments for this age group? Select all that apply. A)Around 5 months, the infant may develop stranger anxiety. B) Around 2 months,the infant exhibits a first real smile. C)Around 3 months, the infant smiles widely and gurgles when interacting with the caregiver. D)Around 3 months, the infant will mimic the parent's facial movements, such as sticking out the tongue. E)Around 3 to 6 months of age, the infant may enjoy socially interactive games such as patty-cake and peek-a-boo. F)Separation anxiety may also start in the last few months of infancy.

ANS: B, C, D, F Feedback: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.

The nurse is teaching a new mother the proper techniques for breastfeeding her newborn. Which is a recommended guideline that should be implemented? A)Wash the hands and breasts thoroughly prior to breastfeeding. B)Stroke the nipple against the baby's chin to stimulate wide opening of the baby's mouth. C)Bring the baby's wide-open mouth to the breast to form a seal around all of the nipple and areola. D)When finished, the mother can break the suction by firmly pulling the baby's mouth away from the nipple.

ANS: C Feedback:Before each breastfeeding session, mothers should wash their hands, but it is not necessary to wash the breast in most cases. The mother should then stroke the nipple against the baby's cheek to stimulate opening of the mouth and bring the baby's wide-open mouth to the breast to form a seal around all of the nipple and areola. When the infant is finished feeding, the mother can break the suction by inserting her finger into the baby's mouth.

The nurse is performing a health assessment of a 3-month-old African-American boy. For what condition should this infant be monitored based on his race? A)Jaundice B)Iron deficiency C)Lactose intolerance D)Gastroesophageal reflux disease (GERD)

ANS: C Feedback:Many dietary practices are affected by culture, both in the types of food eaten and in the approach to progression of infant feeding. Some ethnic groups tend to be lactose intolerant (particularly blacks, Native Americans, and Asians); therefore, alternative sources of calcium must be offered. Jaundice, iron deficiency, and GERD are not seen at a significantly higher rate in African-American infants.

The nurse is assessing a 12-month-old boy with an English-speaking father and a Spanish-speaking mother. The boy does not say mama or dada yet. What is the priority intervention? A)Performing a developmental evaluation of the child B)Encouraging the parents to speak English to the child C)Asking the mother if the child uses Spanish words D)Referring the child to a developmental specialist

ANS: C Feedback: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.

The nurse is examining a 10-month-old boy who was born 10 weeks early. Which finding is cause for concern? A)The child has doubled his birth weight. B)The child exhibits plantar grasp reflex. C)The child's head circumference is 49.53 cm. D)No primary teeth have erupted yet.

ANS: CFeedback:The child's head size is large for his adjusted age (7.5 months), which would be cause for concern. The average head circumference of the full-term newborn is 35 cm (13.5 in). Head circumference increases about 10 cm from birth to 1 year (Levine, 2019). Birth weight doubles by about 4 months of age. Plantar grasp reflex does not disappear until 9 months adjusted age. Primary teeth may not erupt until 8 months adjusted age.

The nurse is providing discharge teaching regarding formula preparation for a new mother. Which guideline would the nurse include in the teaching plan? A)Always wash bottles and nipples in hot soapy water and rinse well; do not wash them in the dishwasher. B)Store tightly covered ready-to-feed formula can after opening in refrigerator for up to 24 hours. C)Warm bottle of formula by placing bottle in a container of hot water, or microwaving formula. D)Do not add cereal to the formula in the bottle or sweeten the formula with honey.

ANS: D Feedback: Proper formula preparation includes the following: wash nipples and bottles in hot soapy water and rinse well or run nipples and bottles through the dishwasher; store tightly covered ready-to-feed formula can after opening in refrigerator for up to 48 hours; after mixing concentrate or powdered formula, store tightly covered in refrigerator for up to 48 hours; do not reheat and reuse partially used bottles; throw away the unused portion after each feeding; do not add cereal to the formula in the bottle; do not sweeten formula with honey; warm formula by placing bottle in a container of hot water; and do not microwave formula.

The nurse is promoting a healthy diet to guide a mother when feeding her 2-week-old girl. Which is the most effective anticipatory guidance? A)Substituting cow's milk if breast milk is not available B)Advocating iron supplements with bottle-feeding C)Advising fluid intake per feeding of 5 or 6 ounces D)Discouraging the addition of fruit juice to the diet

ANS: D Feedback:Discouraging the addition of fruit juice to the child's diet is the most effective anticipatory guidance. Fruit juice can displace important nutrients from breast milk or formula. Cow's milk is likely to result in an allergic reaction. If breast milk is not available, infant formula may be substituted. Advising fluid intake per feeding of 5 or 6 ounces is too much for this neonate, but is typical for an infant 4 to 6 months of age. Advocating iron supplements with bottle-feeding is unnecessary so long as the formula is fortified with iron.

The neonatal nurse assesses newborns for iron deficiency anemia. Which newborn is at highest risk for this disorder? A)A post-term newborn B)A term newborn with jaundice C)A newborn born to a diabetic mother D)A premature newborn

ANS: D Feedback: Maternal iron stores are transferred to the fetus throughout the last trimester of pregnancy. Infants born prematurely miss all or at least a portion of this iron store transfer, placing them at increased risk for iron deficiency anemia compared with term infants. An infant having jaundice, having been born to a mother with diabetes, or having been born postterm does not significantly place the infant at risk for iron deficiency anemia.

The nurse is educating a first-time mother who has a 1-week-old boy. Which is the most accurate anticipatory guidance? A)Describing the effect of neonatal teeth on breastfeeding B)Explaining that the stomach holds less than 1 ounce C)Informing that fontanels will close by 6 months D)Telling that the step reflex persists until the child walks

ANS:B Feedback:Explaining that the child's stomach holds less than 1 ounce gives the mother a reason for frequent, small feedings and is the most helpful and accurate anticipatory guidance. Telling that the step reflex persists until the child walks and informing that fontanels will close by 6 months are inaccurate. The step reflex disappears at about 2 months and fontanels close between 12 and 18 months. Neonatal teeth are highly unusual and need no explanation unless they occur.

The nurse is teaching a new mother about the development of sensory skills in her newborn. What would alert the mother to a sensory deficit in her child? A)The newborn's eyes wander and occasionally are crossed. B)The newborn does not respond to a loud noise. C)The newborn's eyes focus on near objects. D)The newborn becomes more alert with stroking when drowsy.

ANS:B Feedback:Though hearing should be fully developed at birth, the other senses continue to develop as the infant matures. The newborn should respond to noises. Sight, smell, taste, and touch all continue to develop after birth. The newborn's eyes wander and occasionally cross, and the newborn is nearsighted, preferring to view objects at a distance of 8 to 15 in. Holding, stroking, rocking, and cuddling calm infants when they are upset and make them more alert when they are drowsy.

The nurse is providing anticipatory guidance to a mother to help promote healthy sleep for her 3-week-old baby. Which recommended guideline might be included in the teaching plan? A)Place the baby on a soft mattress with a firm, flat pillow for the head. B)Place the head of the bed near the window to provide fresh air, weather permitting. C)Place the baby on his or her back when sleeping. D)If the baby sleeps through the night, wake him or her up for the night feeding.

ANS:C Feedback:Sudden infant death syndrome (SIDS) has been associated with prone positioning of newborns and infants, so the infant should be placed to sleep on the back. The baby should sleep on a firm mattress without pillows or comforters. The baby's bed should be placed away from air conditioner vents, open windows, and open heaters. By 4 months of age, night waking may occur, but the infant should be capable of sleeping through the night and does not require a night feeding.

A mother is concerned about her infant's spitting up. Which suggestion would be most appropriate? A)Put the infant in an infant seat after eating." B)Limit burping to once during a feeding." C)Feed the same amount but space out the feedings." D)Keep the baby sitting up for about 30 minutes afterward."

ANS:D Feedback: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.

What information would the nurse include when teaching the parents of an infant about colic?

Colic symptoms will probably fade at 3 months of age. Explanation: Colic is defined as inconsolable crying that lasts 3 hours or longer per day and which it has no physical cause. Colic symptoms typically fade around 3 months of age. This is an age when infants are better able to console themselves. Colic can be very stressful for parents and lead to sleep deprivation. Many infants need to be carried at all times to reduce crying. Some do well with non-nutritive sucking and others need white noise or motion to help them soothe. Because colic has no physical cause, telling the parents about follow up for "nervous stomach" is not necessary. The infant should be placed in a position of comfort to reduce the crying. Every infant has his or her own position that helps; don't just place the infant on his or her back. Doubling up the formula will not help colic and may actually cause more problems because it can cause abdominal pain and increased weight gain

The nurse is assessing an infant at the 6-month well-baby check-up. The nurse notes that at birth the baby weighed 8 lb (3600 g) and was 20 in (50.8 cm) in length. Which finding is consistent with the normal infant growth and development

weight of 16 lb (7300 g) and length of 26 in (66.0 cm) Explanation: The average newborn weighs 7.5 lb (3400 kg) at birth. Most infants double their birth weight at 4 to 5 months and will triple by the time they are 1 year old. If this infant was 8 lb (3600 kg) at birth, then it is most likely now 16 lb (7300 g). The average newborn is 20 in (50 cm) long at birth. They grow more quickly in length over the first 6 months, than during the second 6 months. By 12 months of age, the infant's length has increase by 50%. At 1 year, this infant will most likely be 30 in (76.2 cm) in length; however, since most of the growth occurs in the first 6 months, it is possible for the infant to grow an additional 6 in (15 cm) during that time.

The nurse is assessing an infant at the 6-month well-baby check-up. The nurse notes that at birth the baby weighed 8 lb (3600 g) and was 20 in (50.8 cm) in length. Which finding is consistent with the normal infant growth and development?

weight of 16 lb (7300 g) and length of 26 in (66.0 cm) Explanation: The average newborn weighs 7.5 lb (3400 kg) at birth. Most infants double their birth weight at 4 to 5 months and will triple by the time they are 1 year old. If this infant was 8 lb (3600 kg) at birth, then it is most likely now 16 lb (7300 g). The average newborn is 20 in (50 cm) long at birth. They grow more quickly in length over the first 6 months, than during the second 6 months. By 12 months of age, the infant's length has increase by 50%. At 1 year, this infant will most likely be 30 in (76.2 cm) in length; however, since most of the growth occurs in the first 6 months, it is possible for the infant to grow an additional 6 in (15 cm) during that time.