N306_Chapter 15 newborn
A mother calls a clinic nurse to ask if her infant born prematurely should receive the seasonal influenza vaccine. The nurse's next question should be: "How old is your baby?" "How premature was your baby?" "Does your baby have any allergies?" "Did your baby have any respiratory problems?"
"How old is your baby?"
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." "I can expect my infant to become clingy around strangers within the next month." "I can expect my infant to be able to hold a rattle within the next month." "I can expect my infant to laugh out loud within the next month."
"I can expect my infant to be able to raise the head up when on the stomach within the next month."
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? "I will place my infant on the back to sleep every night." "I have a crib in my room so that I can breastfeed my baby." "My husband gave the baby a special bear that I will place in the crib." "By keeping the room at a neutral temperature, I do not have to use blankets."
"My husband gave the baby a special bear that I will place in the crib."
The nurse is assessing a 9-month-old child that was born at 32 weeks' gestation. The nurse is aware that the child's growth and development expectations would be at what age group? 6 months old 7 months old 8 months old 9 months old
7 months old When assessing growth and development of an infant or child, determine the child's adjusted or corrected age. To determine this age, subtract how early the child was delivered by the child's chronological age. In this question, the child was born at 32 weeks' gestation or 2 months early, so subtract 2 months from 9 months. The child's corrected age is 7 months.
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? "Make sure that you test the milk on your wrist before feeding." "You should warm the milk under warm water instead." "Breast milk can be given cold, so there is no need to heat it." "You should only give fresh breast milk to an infant."
"You should warm the milk under warm water instead."
The nurse is assessing the cardiac sounds of a child. Which action would the nurse incorporate into the assessment? Auscultate the heart sounds with the child in both the upright and the prone positions. Auscultate the heart rate at the point of maximal impulse (PMI) to best interpret the cardiac sounds. Auscultate the apical heart rate for 30 seconds and multiply by 2 to obtain the beats/minute. Auscultate the cardiac sounds over the three prominent valvular areas on the chest.
Auscultate the heart rate at the point of maximal impulse (PMI) to best interpret the cardiac sounds.
The nurse is assessing an infant who is being breast-fed. Which observation regarding the infant's stools is expected? Fewer stools Stool will be soft. Stool will be hard. Stool will have a strong odor.
stool will be soft
Anticipatory guidance for an infant for the 4th month should include the fact that the infant will be able to achieve which developmental milestone? develop a fear of strangers be able to turn over onto the back insist on things being done the infant's way have many "blue" or moody periods
be able to turn over onto the back
The rash in roseola is pruritic. Which measure would you teach the parent to provide comfort? Dress the child warmly to bring out the rash so that it fades quickly. Apply cool compresses to the skin to stop local itching. Discuss with the child the importance of not scratching lesions. Administer infant aspirin every 4 hours as necessary for comfort.
Apply cool compresses to the skin to stop local itching.
The English-speaking nurse is assessing a 12-month-old child with an English-speaking father and a Spanish-speaking mother. The child does not use words like "drink" "dog" or "ball." What is the nurse's priority intervention? Performing a developmental evaluation of the child Encouraging the parents to speak only one language to the child Asking the mother if the child uses Spanish words for those items Referring the child to a developmental specialist to rule out developmental delay
Asking the mother if the child uses Spanish words for those items
What mineral is an important factor in tooth development?
fluoride
The nurse is educating the mother of a 6-month-old boy about the symptoms for teething. Which symptom would the nurse identify? running a mild fever or vomiting choosing soft foods over hard foods increased biting and sucking frequent loose stools
increased biting and sucking
An infant is breastfed. When assessing the stools, which findings would be typical? Harder stools than those of bottle-fed infants Fewer stools than bottle-fed infants Less constipation than bottle-fed infants A strong odor
less constipation than bottle fed infants
Parents bring their infant to the clinic because the baby has been vomiting and had diarrhea for the past 3 days. The nurse assesses the infant and finds dry mucous membrane and lethargy. Which other finding would support a nursing diagnosis of fluid volume deficit? sunken fontanel decreased pulse rate increased blood pressure low urine specific gravity
sunken fontanel
When determining the correct therapeutic dose of most medications in children, which assessment would be most important for the nurse to make? Weight Chronological age Length or height Developmental age
weight
A nurse is assessing a Babinski reflex in a 2-day-old newborn. Which finding by the nurse would indicate a positive finding? Dorsiflexion of the newborn's toes Curling downward of the toes Fanning of the infant's toes Withdrawing the foot from touch
Fanning of the infant's toes
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 infant grasps a finger when it is placed in the palm. The infant's toes hyperextend when the bottom of the foot is stroked. The anterior fontanel (fontanelle) is open and easily palpated.
The infant displays an asymmetric tonic neck reflex (fencing reflex).
A breast-feeding mother asks the nurse about when she can begin feeding her 5-month-old infant some solids and vitamins. Which information provided by the nurse would most accurately address this mother's concerns? You can begin feeding the infant fruits and vegetables now followed by iron-enriched cereal to ensure that he gets enough iron. The first food offered to an infant is iron-enriched rice cereal and can be started now. Additionally, the infant needs to receive Vitamin D and iron. If you give him one or two bottles of juice each day, he should get all the vitamins he needs. You can begin fruits and cereal in 1 month. At 6 months, you need to quit breast-feeding because he is not getting enough iron or Vitamin C and D and that should help him transition to solids better.
The first food offered to an infant is iron-enriched rice cereal and can be started now. Additionally, the infant needs to receive Vitamin D and iron.
The clinic nurse is assessing a 9-month-old client. The parents state, "Our baby is having a really hard time teething." Which nursing action is appropriate? Encourage the parents to feed the infant warmer foods while teething. Have the parent's apply a topical numbing cream to the infant's gums hourly. Tell the parents to give the infant acetaminophen every 4 hours. Recommend the parents provide the infant a cold teething ring to chew
Recommend the parents provide the infant a cold teething ring to chew
Patty 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 questions to see what the problem might be." "Yes, infants cry all the time at that age." "No, call your doctor." "Yes, maybe she is just tired."
"Let me ask you some questions to see what the problem might be."
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." "We can use skin-to-skin kangaroo care before and after." "We hope you are using a very tiny needle." "We can offer him nonnutritive sucking to calm him."
It's better if we're not in the room for this
The nurse working in the child clinic observes infant Max. He is 8 months old. What type of activity should the nurse be observing? Max is cooing and babbling. Max is sitting in his car seat looking at a mobile. Max is on the floor picking up blocks from a bucket. Max is in the stroller playing peek-a-boo.
Max is on the floor picking up blocks from a bucket. An infant 8 months old would be able to reach and grasp and pick up objects. The other choices are appropriate for earlier stages of development for an infant
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 plantar reflex The rooting reflex The Babinski reflex
The Moro Reflex The Moro or startle reflex is tested by making a loud sound or moving the crib. The infant will extend and flex arms quickly.
The nurse is examining the genitals of a healthy newborn girl. The nurse should observe which normal finding? swollen labia minora lesions on the external genitalia labial adhesions swollen and red anal area
swollen labia minora The newborn's labia minora is typically swollen from the effects of maternal estrogen. The minora will decrease in size and be hidden by the labia majora within the first weeks. Lesions on the external genitalia are indicative of sexually transmitted infection. Labial adhesions are not a normal finding for a healthy newborn. A swollen and red anal area would be an abnormal finding
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? "This is a primitive reflex known as the plantar grasp." "This is a primitive reflex known as the palmar grasp." "This is a protective reflex known as rooting." "This is a protective reflex known as the Moro reflex."
"This is a primitive reflex known as the palmar grasp."
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. The infant will need future follow-up for a "nervous" bowel. Formula intake should be doubled to keep the infant from losing weight. Symptoms will decrease if the infant is laid on the back after feedings.
Colic symptoms will probably fade at 3 months of age.
An 8-month-old will be hospitalized for surgery. Which preparation by her parents would be most important? Buy a new pair of soft pajamas. Pack her favorite toy. Let her watch her suitcase being packed. Read her a story on hospitalization.
Pack her favorite toy.
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 is normal with infant stool formation." "Is he in pain?" "We will need to collect a stool specimen for analysis."
What does his stool look like?"
What is the correct amount of wet diapers a mature infant should produce each day? An infant should have 1 to 2 wet diapers/day. An infant should have 3 to 5 wet diapers/day. An infant should have 6 to 8 wet diapers/day. An infant should have 9 to 10 wet diapers/day.
an infant should have 6-8 wet diapers a day
A nurse is providing health promotion education to a family of an 11-month-old infant who is eating "finger foods." The nurse knows the parents understand the risk of infant choking when they state which response below? "I can feed our baby Cheerios." "I can feed our baby popcorn." "I can feed our baby raisins." "I can feed our baby lollipops."
"I can feed our baby Cheerios."
The nurse goes in to check on a new mother to see how breastfeeding is going with her new son. The nurse observes the infant is on the mother's lap with the blanket unwrapped, and the mother is washing his face, and gently stroking the baby. The mother has had trouble breastfeeding the last few times. What is the appropriate response from the nurse? "You will never get him to eat all unwrapped like that." "You are doing a wonderful job attempting to wake the baby." "That is not how you get him to eat." "Maybe you should watch the breastfeeding video again."
"You are doing a wonderful job attempting to wake the baby."
The nurse is discussing medications to be given to a child who has been diagnosed with candidiasis. Which of the following medications would most likely be prescribed for the child? Acetaminophen Ampicillin Aspirin Nystatin
nystatin Application of nystatin to the oral lesions every 6 hours is an effective treatment for candidiasis. Treatment for diaper rash caused by candida albicans is the application of nystatin ointment or cream to the affected area.
A parent must administer a medication in syrup form to a 2-month-old infant. The nurse suggests: placing the syrup in an medicine syringe. mixing the syrup in a small amount of formula. using a measured medicine spoon. placing the syrup in a small amount of rice cereal.
placing the syrup in an medicine syringe. The young infant should naturally and easily suck the medicine through a medicine syringe. Formula and rice cereal are essential foods for the infant and the desirability of them should not be altered by the taste of the medication. In addition, a 2-month-old infant is not developmentally ready for spoon feeding of rice cereal or medication from a medicine spoon.
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 infant grasps a finger when it is placed in the palm. The infant's toes hyperextend when the bottom of the foot is stroked. The anterior fontanel (fontanelle) is open and easily palpated.
The infant displays an asymmetric tonic neck reflex (fencing reflex). The tonic neck reflex normally disappears by between 4 and 7 months, the palmar grasp reflex by between 3 and 6 months, and the Babinski reflex (fanning of toes when sole of foot stroked) between 12 and 24 months. Retaining these primitive reflexes may indicate a neurologic abnormality. The anterior fontanel (fontanelle), which remains open for brain growth, closes between 12 and 18 months of age.
When administering medications to an infant, what information will the nurse to consider? The infant will take oral medications more readily after he or she has been fed. The infant will take medications more readily if he or she is allowed to move the head as desired. The oral medication should be directed toward the side of the mouth when using a syringe or dropper. The infant will take a medication more readily if the flavor is disguised.
The oral medication should be directed toward the side of the mouth when using a syringe or dropper.
An infant who is 4 months old continues to be seen at doctor visits for illness prevention. What would be the next scheduled appointment that this infant should attend to be evaluated? The next visit would be in 1 month. The next visit would be at 6 months. The next visit would be in 3 months. The next visit would be at 9 months.
The next visit would be at 6 months.
The nurse in a pediatric clinic is reviewing the chart of an infant who is 12 months old. The infant weighed 8 lb 3 oz (3720 g) at birth. What does the nurse anticipate the infant's weight to be in kilograms if the infant meets normal growth expectations? Record your answer using one decimal place.
11.2 Explanation: Most infants triple their birth weight by 12 months of age. If the infant weighed 8 lb 3 oz (3720 g) at birth, triple that weight at 12 months would be 11160 g. 100 g = 1 kg; 11160 g = 11.16 kg, rounded to 11.2 kg.
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? Encourage the parents to stay home and allow the staff to care for the infant as much as needed. Suggest the parent attend a parenting support group in their home community for special needs children. Schedule a variety of staff members to care for the child during hospitalization. Assess family to determine if nurturing is consistent, and if parental attachment has occurred.
Assess family to determine if nurturing is consistent, and if parental attachment has occurred
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 transfers objects from one hand to the other. The infant stays seated in the tripod position. The infant raises head and chest while on stomach. The infant laughs aloud and responds to name.
The infant raises head and chest while on stomach.
The nurse is conducting home visits for several families with children born prematurely. When screening for growth and development of the children, the nurse would use the infant's corrected age for which child? the 24-month-old born at 28 weeks' gestation the 3-year-old born at 29 weeks' gestation the 4-year-old born at 24 weeks' gestation the 4-year-old twins born at 26 weeks' gestation
the 24-month-old born at 28 weeks' gestation When screening and assessing growth and development, the nurse would use the child's corrected age (age - weeks early) until the age of 3. After the age of 3, the nurse would use the child's chronological age (the actual age of the child) to assess/screen for G/D.
The nurse brings a 2-day-old newborn into the mother's room in the postpartum unit. The mother voices concern that the newborn's hands and feet "look a little blue." Which response by the nurse is best? "New moms often worry that something is wrong. Everything is fine." "This is normal for a newborn. You do not have anything to worry about." "This condition is known as acrocyanosis. It is normal for a newborn, but I will be sure to let the pediatrician know." "This is common for newborns up to several days of age. It happens because of the immature circulatory system trying to get used to being outside the uterus."
"This is common for newborns up to several days of age. It happens because of the immature circulatory system trying to get used to being outside the uterus."
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? "Babies can't tell the difference between people at that age." "Maybe she just knows your voice better than your mother's." "You may be right, since infants can sense their mother's smell as early as 7 days old." "I'm not sure a 4-week-old has developed a sense of smell yet."
"You may be right, since infants can sense their mother's smell as early as 7 days old."
A parent asks the nurse what symptoms to expect with normal teething in the infant. How should the nurse respond? The infant's gumline will be tender. The infant will not play or eat for 2 days. The infant will be constipated for 2 days. The infant's temperature may go as high as 102°F (38.9°C).
the infant's gumline will be tender
What would be a safe temperature of water to bathe baby Ryan in the tub? The water should be 125 °F. The water should be 130 °F. The water should be 135 °F. The water should be 118 °F.
the water should be 118 The water temperature in the home should be set at less than 120 °F to prevent scalding and burning during infant baths.
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? "Giving a bottle of milk when the infant goes to bed can lead to obesity." "Bottles given at bedtime can cause erosion of the enamel on the teeth." "Giving your baby a pacifier at bedtime will satisfy the need to suck." "You could occasionally give your baby a bottle of water at bedtime."
"Bottles given at bedtime can cause erosion of the enamel on the teeth."
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." "I will introduce soft foods for my infant around 6 months of age." "I will give my infant a drinking cup gradually around 6 months." "I will introduce new foods one at a time."
"I will switch to whole milk when my infant is around 6 months of age."
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? "I'll start with baby oatmeal cereal mixed with low-fat milk." "The cereal should be a fairly thin consistency at first." "I can puree the meat that we are eating to give to my baby." "Once he gets used to the cereal, then we'll try giving him a cup."
"I'll start with baby oatmeal cereal mixed with low-fat milk."
The neonatal nurse assesses newborns for iron-deficiency anemia. Which newborn is at highest risk for this disorder? a postterm newborn a term newborn with jaundice a newborn born to a diabetic mother a preterm newborn
a preterm newborn 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 have been born postterm does not significantly place the infant at risk for iron-deficiency anemia.
What is the correct amount of wet diapers a mature infant should produce each day? An infant should have 1 to 2 wet diapers/day. An infant should have 3 to 5 wet diapers/day. An infant should have 6 to 8 wet diapers/day. An infant should have 9 to 10 wet diapers/day.
an infant should have 6-8 wet diapers/day
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 by 12 months of age when weaning is complete as soon as the infant begins to eat fruit
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 caring for an infant who was born prematurely. After completing the assessment and discussing the infant's activities at home with her mother, it is clear that the child is not meeting her developmental milestones. When reporting this in the medical record, what term would be appropriate? developmental delay developmental disability failure to thrive failure to progress
developmental delay
All infants should have their head circumference measured at health assessment visits. Where should the nurse place the tape measure to obtain this measurement? just above the eyebrows through the prominent part of the occiput the center of the forehead to the base of the occiput the hairline in front to the hairline in back the middle of the forehead through the parietal prominences
just above the eyebrows through the prominent part of the occiput