Prep U ch 3
The father of a 6-week-old infant voices concerns about his son's stooling. He further shares that his son grunts and cries when having a bowel movement. What response by the nurse is most appropriate?
"What does his stool look like?" Grunting, crying and straining during bowel movements by infants and newborns is normal. This is due to the immaturity of the gastrointestinal system. The most important thing to do initially is to determine the appearance of the stool. The grunts and cries are not of concern unless the stool is dry and hard, so asking about the characteristics is the initial response. Simply indicating this is normal without having additional information is not the appropriate response. There is no need for a stool specimen based upon the information provided.
Stacy is going to visit her son in the intensive care unit. She has been pumping breast milk and storing it in the fridge. Stacy is making her son's bottle for his feeding and goes to warm the breast milk. What option should the nurse give the mom to prepare the bottle?
"You can use the hot water tap to get warm water to warm the bottle." The nurse should recommend using warm water or a warm-water tap to place the bottle in before feeding. A microwave should never be used; it could create hot spots and burn the infant. The other choices are not recommended and can cause stomach discomfort.
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?
"You may be right, since infants can sense their mother's smell as early as 7 days old." 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 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." 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.
A mother asks the nurse where the microwave is so that she can warm up breast milk to feed her baby. What is the best response by the nurse?
"You should warm the milk under warm water instead." A microwave can heat unevenly and cause burns and therefore should never be used to heat breast milk or formula for an infant. In addition, it can change the immune properties of the breast milk.
The infant weighs 6 lb 8 oz (2,950 g) at birth. If the infant is following a normal pattern of growth, what would be an expected weight for this child at the age of 12 months?
19 lb 8 oz (8825 g) The average newborn weighs 7.5 lb (3400 g). The average newborn loses 10% of birth weight over the first week of life but regains it in about 10 to 14 days. Most infants double their birth weight by 4 to 6 months of age and triple their birth weight by the time they are 1 year old. If the newborn weighed 6 lb 8 oz (2,950 g) at birth and tripled that weight at 12 months, the infant should weigh 19 lb 8 oz (6.5 lb × 3 = 19.5 lb) or 8825 g.
Which developmental milestone would the nurse expect an 11-month-old infant to have achieved?
Sitting independently Infants typically sit independently, without support, by age 8 months. Walking independently may be accomplished as late as age 15 months and still be within the normal range. Few infants walk independently by age 11 months. Building a tower of three or four blocks is a milestone of an 18-month-old. Turning a doorknob is a milestone of a 24-month-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) 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 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 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.
Infant development is best described by which statement?
Development proceeds cephalocaudally. Growth and development both proceed from head to toe, or in a cephalocaudal sequence. The baby needs first to learn to lift the head. Once that developmental milestone has been achieved then progression can occur to rolling over and then learning to sit. Development proceeds in a proximodistal fashion. Skills are learned in a gross motor fashion before developing fine motor skills. Infants may develop skills at different ages but the process is always sequential. Unless there are other problems to interfere with development, all children will develop in the same manner.
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 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 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 parent of a 3-month-old infant is concerned because the infant does not yet sit by oneself. Which statement best reflects average sitting ability?
Most infants do not sit steadily until 8 months; this infant is normal. At 3 months of age the infant should be able to raise the head about 45 degrees when in the prone position. The infant does yet have the developmental skills for sitting. Most infants are unable to sit steadily until 8 months of age. Gross motor skill development does not correlate with tooth eruption. The nurse should reassure the parent that this infant is on tract developmentally.
Which milestone would the nurse expect an infant to accomplish by 8 months of age?
Sitting without support 1. Physical development of infants occurs in a cephalocaudal fashion. That means they must learn to control and lift their heads first. This is followed by the ability to turn over. Once this occurs the remainder of development occurs quickly. Most infants are able to sit unsupported by 8 months. They are able to creep at 9 months and pull to a standing position by 10 months. At 12 months the infant is able to sit from a standing position and is learning to walk.
The nurse 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. 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 nurse is talking to and making facial expressions at a 9-month-old baby girl during a routine office visit. What is the most advanced milestone of language development that the nurse should expect to see in this child?
The infant says "da-da" when looking at her father By 9 months, an infant usually speaks a first word: "da-da" or "ba-ba." The other answers refer to earlier milestones in language development. In response to a nodding, smiling face, or a friendly tone of voice, a 3-month-old infant will squeal with pleasure or laugh out loud. By 4 months, infants are very "talkative," cooing, babbling, and gurgling when spoken to. At 6 months, infants learn the art of imitating. They may imitate a parent's cough, for example, or say "Oh!" as a way of attracting attention.
The 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. 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.
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. 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 parent of an infant asks the nurse when to begin brushing the infant's teeth. What would be the nurse's best response?
as soon as the first tooth erupts Before tooth eruption occurs, parents should clean the infant's gums after feeding with a damp wash cloth. After the first tooth erupts, parents can use a soft bristle tooth brush. Dental hygiene should be part of the infant's everyday care. The American and Canadian Dental Associations recommend the first dental checkup to occur around 1 year of age. Infants should not go to bed with bottles or sippy cups to prevent dental caries.
The nurse is teaching the parents of a 6-month-old infant about proper dental care. Which action will the nurse indicate as most likely to cause dental caries in this infant?
putting the infant to bed with a bottle of milk or juice The nurse will warn against putting the infant to bed with a bottle of milk or juice because this allows the sugar content of these fluids to pool around the infant's teeth at night. Not cleaning the infant's gums when the infant is done eating will have minimal impact on the development of dental caries, as will using a cloth instead of a brush for cleaning teeth when they erupt. Failure to clean the teeth with fluoridated toothpaste is not a problem if the water supply is fluoridated. Fluoridated toothpaste is recommended for use once the infant is able to not swallow during brushing.
The nurse conducting a 6-month well-baby check-up assesses for the presence/absence of the asymmetric tonic neck reflex. At this age the reflex:
should have disappeared. This primitive (not protective) reflex should be present at birth and disappear around age 4 months.
A 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. 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 educating the mother of a newborn about feeding practices. The nurse correctly advises the mother that:
the newborn's stomach can hold between 0.5 oz and 1 oz. The capacity of the normal newborn's stomach is between 0.5 oz and 1 oz. The recommended feeding plan is to use a demand schedule. Newborns may eat as often as 1.5 to 3 hours. Demand scheduled feedings are not associated with problems sleeping at night.
When the nurse discharges a new mom and infant, the nurses notices that the car seat is in the front seat of the car. What is the appropriate response for the nurse to make regarding the car seat?
"Let me go over car seat safety with you, so you can install your car seat properly." The nurse should notice this is not the proper place for a car seat. The car seat should be rear-facing and in the center of the back seat of the car. The nurse would review car seat safety with the mother and have her install the seat properly. The nurse should provide written materials if available. The other responses are not appropriate and do not ensure that proper installation will occur and that infant safety will be maintained.
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." 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 is helping the mother of a 5-month-old boy understand the importance of developmentally appropriate play. Which one of the toys best meets the needs of this child?
A yellow rubber duck for the bath The rubber duck is most appropriate. It is safe, visually stimulating while bobbing on the water, and adds pleasure to bath time. A push-pull toy promotes skill for a walking infant. Pots and pans from the kitchen cupboard are played with successfully after sitting is mastered. A 5-month-old does not have the fine motor coordination to use stacking toys.
The nurse is assessing the 18-month-old infant. The nurse notes the anterior fontanel (fontanelle) has closed. What initial action by the nurse is indicated?
Document the findings as normal. The anterior fontanel (fontanelle) most often closes between 12 and 24 months of age. The closure of the fontanel (fontanelle) at 18 months of age does not signal any health issues for the infant
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.
The infant seems disinterested in the surrounding environment.The infant has frequent episodes of crossed eyes.The infant does not pay attention to noises behind him. 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.
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 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.
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 head An infant at 4 months of age who cannot support his or her 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 able to sit alone without support.
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) 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 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.
"I will not be concerned if my newborn has stools that begin to have a yellowish color to them." "I understand it is normal for newborns to lose 5% to 10% of their bodyweight after birth." "My newborn can see up-close things, like our faces, better than things at a distance." 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.
The nurse is examining an 8-month-old girl for appropriate development during a regular check-up. Which observation points to a developmental risk?
Uses only the left hand to grasp Favoring one hand over the other may be a warning sign that proper motor development is not occurring in the other arm or hand. Grasping small objects with the entire hand is common at 8 months and precedes the pincer grasp, which is used about 2 months later. Crawling with stomach down and being unable to pull to standing are abilities that may not occur for another 4 to 8 weeks.
The 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. 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.
A mother calls the hospital nursing hotline and asks, "My 8-week-old daughter cries 8 hours a day, and she is hard to console. Is that normal?" What should the nurse's response be to this mother?
"Let me ask you some more questions to see if there are symptoms of colic." The nurse should seek more information to assess the infant's symptoms. The symptoms suggest colic, which is characteristic of an infant who cries more than 3 hours a day and is fussy and hard to console. The other responses are nontherapeutic and do not seek further information to gather a history.
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) 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 mother places her newborn on its side after falling asleep. A mother states all of her children like sleeping on their abdomen and this newborn likes it too. A mother places the baby comforter her grandmother made over the newborn's body.A mother states her baby looks too warm, so she is moving the bassinet in front of the air conditioner to cool him off. Newborns and infants should be on their backs when sleeping in order to help prevent sudden infant death syndrome (SIDS). A firm mattress without pillows or comforters should also be used. The baby's bed should be placed away from air conditioner vents, open windows, and open heaters.
The nurse is reviewing the medical record of an infant who is being seen for the 12-month well-child visit. Which finding(s) is normal for this infant? Select all that apply.
infant walks independently, heart rate 101 beats/min, respiratory rate 28 breaths/min The respiratory rate slows from an average of 30 to 60 breaths/min in the newborn to about 20 to 30 breaths/min in the 12-month-old infant. As the cardiovascular system matures, the average pulse rate decreases from 120 to 140 beats/min in the newborn to about 100 beats/min in the 12-month-old infant. Walking independently often occurs at 12 months of age. Head lag should not be present in a 12-month-old infant (usually not present by 4 months of age). A temperature of 100.6°F (38.1°C) is abnormal and could indicate an infection.
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. 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 best way for an infant's parent to help the child complete the developmental task of the first year is to:
respond to the infant consistently. 1. The developmental task of an infant is gaining a sense of trust. The infant develops this sense from the caretakers who respond to the child's needs, such as feeding, changing diapers, being held. It is a continuous process. A sense of trust is difficult to learn if things are constantly changing. Consistently responding to an infant's needs helps to build a sense of trust. An infant is too young to have variability in caretakers. This causes mistrust. The parents or caretakers do not need a special time to talk to the infant each day. It should be done with each interaction. Providing too much stimulus before the infant develops gross motor skills causes frustration from the child and not enjoyment.
A 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." 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 providing anticipatory guidance to the parent of a 2-month-old infant in relation to growth and development. Which statement from the parent demonstrates proper understanding?
"I can expect my infant to be able to raise the head up when on the stomach within the next month." It is expected that a 3-month-old infant can raise the head to 45 degrees while laying on the stomach. Becoming clingy around strangers occurs in the infant around 6 to 8 months of age. The infant can begin to hold a rattle around 5 months of age. At 4 to 5 months, the infant will typically begin to laugh out loud.
Anticipatory guidance for an infant for the 4th month should include the fact that the infant will be able to achieve which developmental milestone?
be able to turn over onto the back At four months of age, the infant is able to lift the head and look around. The infant can roll from prone to supine. When being pulled up, the head leads. The 4-month-old infant can make simple vowel sounds, laugh aloud, and vocalize in 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.