Chapter 29: Nursing Care of a Family with an Infant
10. The mother of an infant asks you when to begin brushing her son's teeth. Your best response would be:
As soon as the first tooth erupts. RATIONALE: Toothbrushing should begin with the eruption of the first tooth.
14. When teaching an infant's mother about bathing her, it would be important to instruct her that:
Bath time provides an opportunity for play. RATIONALE: 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.
5. Anticipatory guidance for an infant for the 4th month should include the fact that she probably will:
Be able to turn over onto the back. RATIONALE: Infants typically turn over front to back at 4 months, enlarging the area of the house that needs to be childproofed.
6. An infant is breast-fed. When assessing her stools, which findings would be typical?
Breast-fed infants are less likely to be constipated than bottle-fed infants. RATIONALE: The stools of breastfed infants tend to be yellow and looser than those of bottle-fed babies.
9. What information would you include when teaching the parents of an infant about colic?
Colic symptoms will probably fade at 3 months of age. RATIONALE: Colic symptoms typically fade at 3 months of age, probably because children begin to maintain a more upright position at that time.
18. The nurse is planning an educational seminar for community members that focuses on the 2020 National Health Goals to promote health during the infant year. What should the nurse include in this seminar? Select all that apply:
Continuing breast-feeding for 6 months RATIONALE: Nurses can help the nation achieve the 2020 National Health Goals to promote health during the infant year by educating parents about the importance of using infant car seats, continuing exclusive breastfeeding for 6 months, and instigating measures to prevent SIDS such as placing infants to sleep on their backs. The introduction of solid food would occur after the age of 6 months. Immunizations are provided throughout the infant year.
26. The mother of a 4-month-old infant is concerned that the baby does not always want to take a bottle. What should the nurse instruct the mother about feeding the baby?
Ensure the environment is quiet during mealtime. RATIONALE: If infants are fatigued or overstimulated, they also may not eat well. Providing a quiet environment away from distractions before mealtime might be the solution to this problem. Healthy happy babies will be hungry at mealtime and will eat. The mother should not force the baby to take a bottle when it is time to do so. Refusing a bottle may mean that the baby is tired, distracted, or ill. The baby does not always need to be seen by a health care provider when a bottle is refused.
13. Which measure would you suggest an infant's parents use to relieve teething discomfort?
Give her a cold teething ring to chew. RATIONALE: Cold can be very soothing for the tender gum lines during teething. A sedative is not necessary for normal teething discomfort.
17. During an assessment, the nurse determines that a 3-month-old baby has a Moro reflex. What does this finding indicate to the nurse?
Most 3-month-olds still have a Moro reflex. RATIONALE: The Moro reflex will begin to fade at age 5 months and disappear by age 6 months. A Moro reflex at age 9 months or 1 year indicates the need for a neurologic examination.
2. A 3-month-old still has a Moro reflex. Which statement is most true of this reflex?
Most 3-month-olds still have a Moro reflex. RATIONALE: Typically, Moro (startle) reflexes last until 5 to 6 months and then fade.
1. The mother of a 3-month-old is concerned because her daughter does not yet sit by herself. Which statement best reflects average sitting ability?
Most babies do not sit steadily until 8 months; she is normal. RATIONALE: Many infants sit steadily by 8 months of age.
25. A new mother asks the nurse when toothbrushing should begin for the baby. Which response is the most appropriate for the nurse to make at this time?
Now RATIONALE: Toothbrushing can begin even before teeth erupt by rubbing a soft washcloth over the gum pads. This eliminates plaque and reduces the presence of bacteria, creating a clean environment for the arrival of first teeth. Dental care should begin before the age of 12 months, before solid food is eaten, and before the first tooth appears.
4. The best way for an infant's father to help his child complete the developmental task of the first year is to:
Respond to her consistently. RATIONALE: 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.
19. What should the nurse instruct a parent to help a child complete Erikson's developmental task during the infant period?
Respond to the child's needs consistently. RATIONALE: Consistently responding to an infant's needs helps to build a sense of trust, which is Erikson's developmental task during the infant period. Stimulation with toys, talking at a special time each day, and exposing too many caregivers will not help the child develop a sense of trust.
24. The nurse is visiting a mother who has a 3-month-old infant who has been hospitalized for cardiac problems. Which nursing diagnosis should the nurse use to guide care for this family at this time?
Risk for impaired parenting related to the hospitalization of infant. RATIONALE: The diagnosis appropriate for the family whose infant has been hospitalized would be risk for impaired parenting related to hospitalization. There is no evidence to suggest that the mother is not adjusting to parenthood. There is no information about the infant's feeding schedule. There is no information to suggest the mother has a knowledge deficit regarding normal infant growth and development.
7. Which milestone would you expect an infant to accomplish by 8 months of age?
Sitting without support. RATIONALE: Most babies sit steadily at 8 months, creep at 9 months, and pull to standing at 10 months.
21. The nurse is assessing an infant who is being breast-fed. Which observation regarding the infant's stools is expected?
Stool will be soft. RATIONALE: Stools of breast-fed infants are generally softer than those of formula-fed infants. Stools of breastfed infants are not fewer in number, hard, nor have a strong odor.
22. 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. RATIONALE: Sitting a baby in an infant chair for a half an hour after a feeding can help reduce spitting up. Forceful episodes of vomitus and vomiting large amounts after feedings should be reported to the health care provider. Changing the formula will not impact the amount of spitting up the baby.
20. 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. RATIONALE: Infants typically turn over from the front to back at age 4 months. Fear of strangers will not occur until 7 months. The nurse has no way of knowing the infant's temperament to determine that the child will be moody or when the child will expect things to be done a certain way.
27. A new mother asks the nurse what she should look for when the baby starts to teethe. What should the nurse explain to the mother?
The child's gum line will be tender. RATIONALE: Gums are sore and tender before a new tooth breaks the surface. As soon as the tooth is through, the tenderness passes. A high temperature is not a normal expectation with teething and should be reported to the health care provider. The child may resist chewing because of the sore gum; however, it may not last for 2 days. Playing may or may not be affected. Constipation is not an expectation with teething.
12. A father asks the nurse what symptoms he can expect with normal teething in his infant. What would the nurse tell him?
The child's gumline will be tender. RATIONALE: Normal teething creates tender gumlines but does not include an elevated temperature or constipation.
28. During a home visit, the nurse observes a 9-month-old child bang his head against the headboard of the crib at naptime. What should the nurse explain to the mother about this observation?
This action is normal up until preschool age. RATIONALE: Head banging that begins during the second half of the first year of life and continuing through to the preschool period, associated with naptime or bedtime, and lasting under 15 minutes can be considered normal. Children use this measure to relax and fall asleep. Head banging does not mean that the child is eating too much protein or is not getting enough to eat. The child does not need to be seen immediately by a health care provider.
3. Which developmental task, according to Erikson, should an infant accomplish during the infant year?
Trust RATIONALE: The developmental task of the infant year, according to Erikson, is to gain a sense of trust or knowing how to love.
11. Estimating illness in an infant is difficult. To help an infant's parents do this, which of the following would you instruct them to use?
Use her interest in eating as a good gauge. RATIONALE: A healthy infant eats well, voids adequately, and gains weight.
8. The nurse is caring for a 2-month-old with colic. When assessing the infant, the nurse asks her parents about her bowel movements. Which characteristics of the bowel movement are anticipated in a child with colic?
Yellow and semi-formed. RATIONALE: There is no change in characteristics of the bowel movements in an infant with colic. Infants have yellow seedy and typically semi-formed stools. Stools are typically normal in amount, consistency, and color.
15. Infant development is best described by which statement?
Development proceeds cephalocaudally. RATIONALE: Growth and development both proceed from head to toe, or in a cephalocaudal sequence.
29. The nurse observes a new mother bathing her 9-month-old baby. Which observation indicates that the experience is positive for both mother and infant?
The baby is moving the arms and hand and smiling. RATIONALE: Bath time should be fun for an infant and can serve many functions. Especially during the second half of the first year, a child enjoys poking at soap bubbles on the surface of the water or playing with bath toys. Bath time also helps an infant learn different textures and sensations and provides an opportunity to exercise and kick as well as a good opportunity for a parent to touch and communicate with the child. Crying, screaming, reaching for the mother, and trying to avoid touching the water indicates that the bath experience is not positive for the baby or the mother.
16. The mother of a 3-month-old baby is concerned because the child is not able to sit independently. How should the nurse respond to this mother's concern?
Most babies do not sit steadily until 8 months. RATIONALE: An 8-month-old child can sit securely without any additional support. Babies are not able to sit steadily at age 3 or 4 months. Sitting ability does not correspond with tooth eruption.
30. The nurse is concerned that a 9-month-old baby is gaining too much weight. What should the nurse instruct the parents to help control the baby's weight gain?
Provide whole-grain cereal for one feeding. RATIONALE: A way to prevent obesity is to add a source of fiber such as whole-grain cereal to the infant's diet. This prolongs the stomach-emptying time and helps reduce food intake. Nonfat milk should not be given because it contains little essential fatty acids and will not ensure cell growth. The baby should not be given refined sugars such as diluted gelatin or pudding because this will encourage weight gain.
23. The nurse is assessing a 2-month-old formula-fed infant who is experiencing colic. Which type of bowel movements should the nurse expect to occur with this health problem?
Yellow and semisoft. RATIONALE: With colic, bowel movements are normal. For an infant who is formula-fed this means the stool will be yellow and semisoft. Colic does not affect the type of bowel movement so changes in the stool such as hard and lumpy, foul-smelling and bulky, and loose and mucus-streaked should be reported to the health care provider.