Care of the Newborn and Infant

The nurse comes into an infant's room on the pediatric floor. The nurse wants to try to feed the infant for the first time since her surgery. How does the nurse know what state the infant is in by what the mother says, and that it's fine to try and feed the infant?

"She has been a chatterbox and smiles just like her brother."

The parent of a 4-day-old infant brings the infant to the clinic concerned about the infant's hands and feet appearing blue. What is the nurse's best response during the admission process?

"This is often a normal occurrence in infants of this age, but we will have the health care provider assess your infant."

The nurse is assessing for pain in a 2-month-old infant. Which behavior indicates that this baby is experiencing pain?

Continued crying after diaper change and being fed

A 3-month-old infant has a Moro reflex. Which statement is most true of this reflex?

Infant may retain the Moro reflex at 3 month old; it fades between 2 and 4 months.

The nursing instructor is conducting a clinical session on the proper techniques for assessing a child's head circumference. The instructor should point out which factor concerning this assessment?

Place the tape measure around the head just above the eyebrows.

A mother and her 4-week-old infant have arrived for a health maintenance visit. Which activity will the nurse perform?

Plot the child's head circumference on a growth chart.

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.

The nurse is educating the mother of a 6-month-old boy about the symptoms for teething. Which symptom would the nurse identify?

increased biting and sucking

The nurse is examining the genitals of a healthy newborn girl. The nurse should observe which normal finding?

swollen labia minora

The nurse is talking with the mother of a 6-month-old who was born at 32 weeks' gestation about nutrition-related concerns. The mother questions the nurse about when additional foods may be added to the diet. She remarks that her older child was started on additional foods between 4 and 6 months of age. What response by the nurse is most appropriate?

"The addition of foods to your baby's diet may be slightly delayed because of his prematurity."

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 mostappropriate?

"What does his stool look like?"

The nurse is assessing a 3-year-old child. The nurse notes the child is able to understand that objects hidden from sight still exist. The nurse correctly documents that the child is displaying:

object permanence

The nurse observes an infant interacting with his parents. What are normal social behavioral developments for this age group? Select all that apply.

-Around 3 months the infant will mimic the parent's facial movements, such as sticking out the tongue. -Around 3 months the infant smiles widely and gurgles when interacting with the caregiver. -Around 2 months the infant exhibits a first real smile. -Separation anxiety may also start in the last few months of infancy.

The rash in roseola is pruritic. Which measure would you teach the parent to provide comfort?

Apply cool compresses to the skin to stop local itching.

The nurse is planning interventions for an infant. The infant has been hospitalized for several weeks due to a chronic illness. Which intervention will assist the infant in developing a sense of trust?

Assess family to determine if nurturing is consistent, and if parental attachment has occurred.

The parents of a newborn diagnosed with a chronic illness ask the nurse, "How will this effect our newborn's growth and development?" Which nursing response is most appropriate?

"It is common for newborn with chronic illnesses to grow and develop at a slower pace."

The public health nurse is discussing immunizations with a group of caregivers of infants. One of the mothers asks the nurse why the child will need immunizations. Which statement would be the most appropriate for the nurse to make to this mother?

"The infant is born with immunity to some diseases, but those immunities decrease over the first year of life."

The nurse is preparing to give a 4-month-old an oral medication. Which technique demonstrates the nurse's accurate knowledge of the infant's developmental level?

Position the infant upright, offer the infant a bottle of formula, remove the bottle and squirt the medication on the side of the tongue toward the cheek, then offer the infant the bottle again.

The nurse is visiting a mother who has a 3-month-old infant. Which anticipatory guidance information should the nurse provide to the mother at this time?

The child should be able to turn over onto the back at age 4 months.

A nurse is preparing to administer vaccines to a 4-month-old infant. Which vaccines will the nurse administer? Select all that apply.

Haemophilus B inactivated poliomyelitis diphtheria, tetanus, and pertussis pneumococcal

A 2-week-old child responds to a bell during an initial health supervision examination. The child's records do not show that a newborn hearing screening was done. Which is the best action for the nurse to take?

Immediately schedule the infant for a newborn hearing screening.

The pediatric nurse is meeting with a group of young mothers of newborn infants who are questioning the "soft spot" on the head and when it will close. Which fact should the nurse point out to the mothers?

May increase slightly in size the first few months of life

The mother of an infant is confused after being told by her dentist not to let her baby go to bed with a bottle of milk. She does not agree with that suggestion. Which response should the nurse prioritize when addressing this situation with the mother?

"Bottles given at bedtime can cause erosion of the enamel on the teeth."

The nurse has just finished administering the DTaP vaccine to a 2-month-old and is educating the parent about immunization. Which statement is accurate?

"Bring her back for the second dose when she is 4 months old."

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.

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?

The newborn does not respond to a loud noise.

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."

A nurse is providing health promotion education to a family of an infant at the family birth center. The nurse knows the parents need more education when they state which response?

"I will switch to whole milk when my infant is around 6 months of age."

The nurse is providing teaching to the parents of a newborn prior to a heelstick. The nurse is describing the procedure and recommending various methods for the parents to help comfort their baby. Which statement by the parents indicates a need for further teaching?

"It's better if we are not in the room for this."

A mother is concerned about her infant's spitting up. Which suggestion would be mostappropriate?

"Keep the baby sitting up for about 30 minutes afterward."

What mineral is an important factor in tooth development?

Fluoride

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

Sitting without support

The nurse is assessing a 12-week-old infant in the clinic at a well-baby visit. Which assessment finding does the nurse predict to assess in this healthy infant?

Smiles at significant others

The nurse is assessing reflexes on a neonate. When assessing which reflex is the nurse most correct to clap during the assessment technique?

The Moro reflex

The nurse is identifying outcomes for care provided to a new mother whose infant continues to spit up after feedings. Which outcome would be the most appropriate?

The baby will have less episodes of spitting up after sitting upright after a feeding

The pediatric nurse is careful to monitor and assess the growth and development of all clients. Which characteristic should the nurse prepare to assess in the infants?

Grows and develops skills more rapidly than at any other time in their life.

The best way for an infant's parent to help the child complete the developmental task of the first year is to:

respond to the infant consistently.

The nurse is preparing a presentation for a health fair illustrating the major milestones of infants as they grow and develop. Which fact should the nurse point out when illustrating an infant's teeth?

The first tooth usually erupts by 6 months.

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

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

The nurse is providing care to an infant experiencing pain. Which of the following would be most appropriate for the nurse to implement?

Using rhythmic, continuous horizontal motions while holding Coating a pacifier with an oral sucrose solution for sucking Tightly wrapping in a blanket with extremities flexed and hands uncovered

The nurse is preparing to measure the head circumference of a 6-month-old infant. How should the nurse make this measurement?

from above the eyebrows through the prominent part of the occiput

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.

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.