Chapter 35: The Infant and Family

The nurse is doing a routine assessment on a 14-month-old infant and notes that the anterior fontanel is closed. How should the nurse interpret this finding? a. It is a normal finding. b. It is a questionable finding—the infant should be rechecked in 1 month. c. It is an abnormal finding—it indicates the need for immediate referral to practitioner. d. It is an abnormal finding—it indicates the need for developmental assessment.

ANS: A Because the anterior fontanel normally closes between ages 12 and 18 months, this is a normal finding, and no further intervention is required.

The nurse is interviewing the father of 12-month-old Megan. She is playing on the floor when she notices an electrical outlet and reaches up to touch it. Her father says "No" firmly, and moves her away from the outlet. To teach the father, the nurse should say which applies to Megan at this developmental level? a. She is old enough to understand the word "No." b. She is too young to understand the word "No." c. She should already know that electrical outlets are dangerous. d. She will learn safety issues better if she is spanked.

ANS: A By age 12 months, children are able to associate meaning with words. A 12-month-old child should understand the word "no" but is too young to understand the purpose of an electric outlet. The father is using both verbal and physical cues to alert the child to dangerous situations. Physical discipline should be avoided.

In terms of fine motor development, which action should a 7-month-old infant be able to perform? a. Transfer objects from one hand to the other. b. Use thumb and index finger in crude pincer grasp. c. Hold crayon and make a mark on paper. d. Release cubes into a cup.

ANS: A By age 7 months, infants can transfer objects from one hand to the other, crossing the midline. The pincer grasp is apparent at about age 10 months. The child can scribble spontaneously at age 15 months. At age 11 months, the child can place objects into a cup or container.

The parents of a 4-month-old infant tell the nurse that they are getting a microwave oven and will be able to heat the baby's formula faster. What information should the nurse provide to the parents about heating infant formula in a microwave? a. Never heat a bottle in a microwave oven. b. Heat only 300 mL or more. c. Stop halfway through warming and invert the bottle a few times. d. Shake the bottle vigorously for at least 30 seconds after heating.

ANS: A Health Canada does not recommend microwaving infant formula or breast milk, but rather encourages the use of conventional warming methods.

Sara, age 4 months, was born at 35 weeks' gestation. She seems to be developing normally, but her parents are concerned because she is a "more difficult" baby than their other child, who was term. How should the nurse explain this difference to the parents? a. Infants' temperaments are part of their unique characteristics. b. Infants become less difficult if they are not kept on scheduled feedings and structured routines. c. Sara's behaviour is suggestive of failure to bond completely with her parents. d. Sara's difficult temperament is the result of painful experiences in the newborn period.

ANS: A Infant temperament has a strong biological component. Together with interactions with the environment, primarily the family, the biological component contributes to the infant's unique temperament. Children perceived as difficult may respond better to scheduled feedings and structured caregiving routines rather than demand feedings and frequent changes in routines. The nurse should provide guidance in parenting techniques that are best suited to Sara's temperament.

In terms of gross motor development, what can the nurse expect a 5-month-old infant to do? a. Roll from abdomen to back. b. Roll from back to abdomen. c. Sit erect without support. d. Move from prone to sitting position.

ANS: A Rolling from abdomen to back is developmentally appropriate for a 5-month-old infant. The ability to roll from back to abdomen usually occurs at 6 months old. Sitting erect without support is a developmental milestone usually achieved by 8 months. The 10-month-old infant can usually move from a prone to sitting position.

What information can be given to the parents of a 12-month-old child regarding appropriate play activities for this age? a. Introduce large push-pull toys for kinetic stimulation. b. Place a cradle gym across his crib to facilitate fine motor skills. c. Provide finger paints to enhance fine motor skills. d. Provide a stick horse to develop gross motor coordination.

ANS: A The 12-month-old child is able to pull himself to a stand position and walk holding on or independently. Appropriate toys for a child this age include large push-pull toys for kinesthetic stimulation. A cradle gym should not be placed across the crib. Finger paints are more appropriate for older children. A 12-month-old child does not have the stability to use a stick horse.

What is the best play activity for a 6-month-old infant to enhance socialization and cognition? a. Hide the infant's head in a towel. b. Give the infant various coloured blocks. c. Play a music box, CDs, or MP3 player. d. Use an infant swing or stroller.

ANS: A The 6-month-old infant laughs when his or her head is hidden in a towel, thus promoting socialization and cognition. Various coloured blocks provide visual stimulation for a 4- to 6-month-old. Songs from a music box, CDs, or MP3 player provide auditory stimulation. Swings and strollers provide kinesthetic stimulation.

A 3-month-old infant, born at 38 weeks of gestation, will hold a rattle if it is put in her hands, but she will not voluntarily grasp it. How should the nurse interpret this behaviour? a. This is normal development. b. This is a significant developmental lag. c. This is slightly delayed development caused by prematurity. d. This is suggestive of a neurological disorder such as cerebral palsy.

ANS: A This action indicates normal development. Reflexive grasping occurs during the first 2 to 3 months and then gradually becomes voluntary. No evidence of neurological dysfunction is present.

A nurse is assessing a 6-month-old healthy infant who weighed 3 kg at birth. How many kilograms should the nurse expect the infant to weigh now? a. 4 kg b. 6 kg c. 9 kg d. 12 kg

ANS: B Birth weight doubles at about age 5 to 6 months. At 6 months, a child who weighed 3 kg at birth would weigh approximately 6 kg.

When assessing an 8-month-old infant, which findings would the nurse expect to observe? Select all that apply. Express answer in small letters followed by a comma and a space—e.g., a, b, c. a. Parachute reflex b. Releases objects at will c. Makes consonant sounds t, d, w d. Labyrinth-righting reflex is strong e. Can change from prone to sitting position f. Recovers balance easily while sitting g. Creeps on hands and feet

ANS: A, B, C An 8-month-old can release objects at will, can make consonant sounds, and has a parachute reflex. Labyrinth-righting reflex, changing position from prone to sitting, and recovering balance easily while sitting are all characteristic of a 10-month-old. A 9-month-old can creep on hands and feet.

At what age should the nurse expect an infant to begin smiling in response to pleasurable stimuli? a. 1 month b. 2 months c. 3 months d. 4 months

ANS: B At age 2 months the infant has a social, responsive smile. A reflex smile is usually present at age 1 month. The 3-month-old can recognize familiar faces. At age 4 months the infant can enjoy social interactions.

Pacifiers can be extremely dangerous because of the frequency of use and the intensity of the infant's suck. A nurse is teaching parents about appropriate pacifier selection—which characteristic should a pacifier have? a. No handle b. One-piece construction c. Ribbon or string to secure to clothing d. Soft, pliable material

ANS: B One-piece construction is necessary to prevent the nipple and guard from separating. A good pacifier should be easily grasped by the infant; therefore, it must have a handle. The material should be sturdy and flexible. An attached ribbon or string and soft, pliable material are not characteristics of a good pacifier.

When is the best age for solid food to be introduced into the infant's diet? a. 3 months b. 6 months c. When birth weight has tripled d. When tooth eruption has started

ANS: B Physiologically and developmentally, the 6-month-old is in a transition period. The extrusion reflex has disappeared, and swallowing is a more coordinated process. In addition, the gastrointestinal tract has matured sufficiently to handle more complex nutrients and is less sensitive to potentially allergenic food. Infants of this age will try to help during feeding. Age 2 to 3 months is too young, in part because the extrusion reflex is still strong, and the child will push food out with the tongue. No research indicates that the addition of solid food to a bottle has any benefit. Infant birth weight triples at 1 year, but solid foods can be started earlier. Tooth eruption can facilitate biting and chewing, but most infant foods do not require this ability.

The clinic is lending a federally approved car seat to an infant's family. Where is the safest place to put the car seat? a. Front-facing in the back seat b. Rear-facing in the back seat c. Front-facing in the front seat with airbag on the passenger side d. Rear-facing in the front seat if an air bag is on the passenger side

ANS: B The rear-facing car seat provides the best protection for an infant's disproportionately heavy head and weak neck. Infants should face the rear from birth until they weigh 9 kg (20 lbs) and are as close to 1 year of age as possible. The middle of the back seat provides the safest position. Severe injuries and deaths in children have occurred from air bags deploying on impact in the front passenger seat.

At which age do most infants begin to fear strangers? a. 2 months b. 4 months c. 6 months d. 12 months

ANS: C Between ages 6 and 8 months, fear of strangers and stranger anxiety become prominent and are related to the infant's ability to discriminate between familiar and unfamiliar people. At age 2 months, infants are just beginning to respond differentially to the mother. At age 4 months the infant is beginning the process of separation individuation, recognizing self and mother as separate beings. Twelve months is too late and requires referral for evaluation if the child does not fear strangers at this age.

A mother tells the nurse that she is discontinuing breastfeeding her 5-month-old infant. What should the nurse recommend that the infant be given? a. Skim milk b. Whole cow's milk c. Commercial iron-fortified formula d. Commercial formula without iron

ANS: C If breastfeeding has been discontinued, iron-fortified commercial formula should be used. Cow's milk should not be used in children younger than 12 months. Maternal iron stores are almost depleted by this age; the iron-fortified formula will help prevent the development of iron-deficiency anemia.

According to Piaget, a 6-month-old infant is in which stage of the sensorimotor phase? a. Use of reflexes b. Primary circular reactions c. Secondary circular reactions d. Coordination of secondary schemata

ANS: C Infants are usually in the secondary circular reaction stage from age 4 to 8 months. This stage is characterized by a continuation of the primary circular reaction for the response that results. Shaking is performed to hear the noise of the rattle, not just for shaking. Infants use reflexes primarily during the first month of life. The primary circular reaction stage marks the replacement of reflexes with voluntary acts. The infant is in this stage from 1 to 4 months of age. The fourth sensorimotor stage is coordination of secondary schemata. This is a transitional stage in which increasing motor skills enable further exploration of the environment.

By what age should the nurse expect that an infant will be able to pull herself into a standing position? a. 6 months b. 8 months c. 11 to 12 months d. 14 to 15 months

ANS: C Most infants can pull themselves to a standing position at age 9 months. Infants who are not able to pull themselves up to standing by age 11 to 12 months should be further evaluated for developmental dysplasia of the hip. At 6 months, the infant has just obtained coordination of arms and legs. By age 8 months, infants can bear full weight on their legs.

At which age can most infants sit steadily unsupported? a. 4 months b. 6 months c. 8 months d. 10 months

ANS: C Sitting erect without support is a developmental milestone usually achieved by 8 months. At age 4 months an infant can sit with support. At age 6 months, the infant will maintain a sitting position if propped. By 10 months the infant can manoeuvre from a prone to a sitting position.

Latasha is a breastfed infant being seen in the clinic for her 6-month checkup. Her mother tells the nurse that she recently began to suck her thumb. Which is the best action for the nurse to take? a. Recommend that the mother substitute a pacifier for her thumb. b. Assess Latasha for other signs of sensory deprivation. c. Reassure the mother that this is very normal at this age. d. Suggest that the mother breastfeed Latasha more often to satisfy sucking needs.

ANS: C Sucking is an infant's chief pleasure, and she may not be satisfied by bottle-feeding or breastfeeding alone. During infancy and early childhood there is no need to restrict non-nutritive sucking, as it is a normal behaviour. Dental damage does not appear to occur unless the use of the pacifier or finger persists after age 4 to 6 years. The nurse should explore with the mother her feelings about a pacifier versus thumb. Thumb-sucking is not evidence supporting that Latasha has experienced sensory deprivation.

Parents tell the nurse that their 1-year-old son often sleeps with them. They seem unconcerned about this. The nurse's response should be based on knowing that which is accurate? a. Children should not sleep with their parents. b. Separation from parents should be completed by this age. c. Daytime attention should be increased. d. This is a common and accepted practice, especially in some cultural groups.

ANS: D Co-sleeping or sharing the family bed, where parents allow their children to sleep with them, is a common and accepted practice in many cultures. Parents should evaluate the options available and avoid conditions that place an infant at risk. Population-based studies are currently underway; no evidence at this time supports or condemns the practice for safety reasons. At 1 year of age, children are just beginning to individuate. Increased daytime activity may help decrease sleep problems in general, but co-sleeping is a culturally determined phenomenon.

The parents of a 12-month-old child ask the nurse if the child can eat hot dogs. Which should inform the nurse's reply? a. The child is too young to digest hot dogs. b. The child is too young to eat hot dogs safely. c. Hot dogs must be sliced into sections to prevent aspiration. d. Hot dogs must be cut into small, irregular pieces to prevent aspiration.

ANS: D Hot dogs are of a consistency, diameter, and round shape that may cause complete obstruction of the child's airway. If given to young children, they should be sitting down and the hot dog should be cut into small, irregular pieces rather than served whole or in slices. A 12-month-old child's digestive system is mature enough to digest hot dogs.

Austin, age 6 months, has six teeth. What should the nurse recognize about this assessment finding? a. This is normal tooth eruption. b. This is delayed tooth eruption. c. This is unusual and dangerous. d. This is earlier-than-normal tooth eruption.

ANS: D This is earlier than expected. The average number of teeth in 6-month-old infants is two. A quick way to assess the average number of deciduous teeth a child should have during the first 2 years is to subtract 6 from the age of the child in months, which equals the number of teeth. Six teeth at 6 months is not delayed, it is early tooth eruption. Although unusual, it is not dangerous.

What is an appropriate play activity for a 7-month-old infant to encourage socialization and cognition? a. Playing peek-a-boo b. Playing pat-a-cake c. Imitating animal sounds d. Showing how to clap hands

ANS: A Because object permanence is a new achievement, peek-a-boo is an excellent activity to practice this new skill for socialization for the 7-month-old infant. Playing pat-a-cake and showing how to clap hands will help with socialization/cognition at 10 months of age. Imitating animal sounds will help with vocalization at 12 months of age.

By what age does the posterior fontanel usually close? a. 6 to 8 weeks b. 10 to 12 weeks c. 4 to 6 months d. 8 to 10 months

ANS: A The bones surrounding the posterior fontanel fuse and close by age 6 to 8 weeks. Ten weeks or longer is too late.

In terms of gross motor development, what does a nurse expect a 5-month-old infant to do? a. Move from prone to sitting position. b. Put feet in mouth when supine. c. Roll from back to abdomen. d. Sit erect without support.

ANS: B The ability to place the feet in the mouth when supine is a developmentally appropriate action for a 5-month-old infant.

Which behaviour indicates that an infant has developed object permanence? a. Recognizes familiar face, such as mother b. Recognizes familiar objects, such as a bottle c. Actively searches for a hidden object d. Secures objects by pulling on a string

ANS: C During the first 6 months of life, infants believe that objects exist only as long as they can see them. When infants search for an object that is out of sight, this signals the attainment of object permanence, whereby an infant knows that an object exists even when it is not visible. Between ages 8 and 12 weeks, infants begin to respond differentially to their mothers. They cry, smile, vocalize, and show distinct preference for their mothers. This preference is one of the stages that influence the attachment process, but it is too early for object permanence. Recognizing familiar objects is an important transition for the infant, but it also does not signal object permanence. The ability to understand cause and effect is part of secondary schema development.

The parent of 2-week-old Sarah asks the nurse if Sarah needs fluoride supplements because she is exclusively breastfed. What is the basis for the nurse's response? a. Fluoride should be started in the neonatal period. b. It is not needed if the newborn has an intake of fluoridated water. c. Fluoride supplements may need to begin at age 6 months. d. Infants can have infant cereal mixed with fluoridated water instead of supplements.

ANS: C Fluoride supplementation may be recommended at age 6 months if the child is not drinking adequate amounts of fluoridated water. The amount of water that is ingested and the amount of fluoride in the water are taken into account when supplementation is being considered.

Which statement best describes the infant's physical development? a. The anterior fontanel closes by age 6 to 10 months. b. Binocularity is well established by age 8 months. c. Birth weight doubles by age 6 months and triples by 1 year of age. d. Maternal iron stores persist during the first 12 months of life.

ANS: C Growth is very rapid during the first year of life. The birth weight has approximately doubled by age 5 to 6 months and triples by 1 year of age. The anterior fontanel closes at age 12 to 18 months. Binocularity is not established until age 15 months. Maternal iron stores are usually depleted by age 6 months.

A mother tells the nurse that she doesn't want her infant immunized because of the discomfort associated with injections. What should the nurse explain to the mother in response to her statement? a. This cannot be prevented. b. Infants do not feel pain as adults do. c. This is not a good reason for refusing immunizations. d. A topical anaesthetic can be applied before injections are given.

ANS: D Several topical anaesthetic agents can be used to minimize the discomfort associated with immunization injections. These include EMLA and vapour coolant sprays. Pain associated with many procedures can be prevented and minimized by using the principles of atraumatic care. Numerous research studies have indicated that infants perceive and react to pain in the same manner as children and adults. The mother should be allowed to discuss her concerns and the alternatives available, as this is part of the informed consent process.

The parents of a 9-month-old infant tell the nurse that they have noticed foods such as peas and corn are not completely digested and can be seen in their infant's stool. Which is accurate as a basis for her explanation? a. The child should not be given fibrous foods until the digestive tract matures at age 4 years. b. The child should not be given any solid foods until this digestive problem is resolved. c. This is abnormal and requires further investigation. d. This is normal because of the immaturity of digestive processes at this age.

ANS: D The immaturity of the digestive tract is evident in the appearance of the stools. Solid foods are passed incompletely broken down in the feces. An excess quantity of fibre predisposes the child to large, bulky stools. This is a normal part of the maturational process, and no further investigation is necessary.