PEDS: Chapter 23: Growth and Development of the Infant
The mother of a 3-month-old infant expresses concern that her infant's head is misshapen. Which would be the most appropriate question by the nurse?
• "Do you use "tummy time" with the infant?"
The nurse is providing anticipatory guidance to the mother of a 2-month-old in relation to interpersonal development. Which behavior is most likely to occur over the next 8 weeks?
• Mimicking mother's facial expressions Mimic facial expressions: 3 to 4 months Clingy around strangers: 6 months Peek-a-boo: 6 and 8 months Crying when mother out of sight; after 6 to 8 months
A 3-month-old infant has a Moro reflex. Which statement is most true of this reflex?
• Most 3-month-old infants still have a Moro reflex. Disappears around 4 months Known as startle reflex
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.
A nurse is educating a client being discharged with her newborn baby. What is the highest priority item that must be included in the teaching plan?
• Restrain the baby in a car seat.
A nurse is educating a client being discharged with her newborn baby. What is the highestpriority item that must be included in the teaching plan?
• Restrain the baby in a car seat.
The nurse is conducting a physical examination of a 5-month-old boy. Which observation may be cause for concern about the infant's neurologic development?
• The infant displays an asymmetric tonic neck reflex (fencing reflex). Should disappear by 4 months Palmar grasp reflex by age 6 months Babinski reflex (fanning of toes when sole of foot stroked) by 12 months Anterior fontanel closes between 12 and 18 months
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 baby is around 6 months of age."
Which measures should receive priority in the care plan for an infant client who has sensitive skin?
• Change diapers frequently
The infant weighs 7 lb 4 oz (3,248 g) at birth. If the infant is following a normal pattern of growth, what would be the expected weight for this child at the age of 12 months?
• 21 lb 12 oz (9.9 kg) By four months: doubled By 1 year: tripled
The nurse is assessing Julie, a 3-month-old infant. Which developmental milestone would the nurse expect?
• Julie can hold her head erect and steady.
An infant is being introduced to drinking fluids from a cup. The nurse instructs the mother that fruit juice can now be added. Which of the following would the nurse suggest the mother try first? Select all that apply.
• Apple • White grape juice
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 hospitalization of infant
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 promoting a healthy diet to guide a mother when feeding her 2-week-old girl. Which is the most effective anticipatory guidance?
• Discouraging the addition of fruit juice to the diet
The nurse is teaching the parents of an infant about bathing. The nurse will inform the parents to set the home hot water heater to which temperature?
• 115°F (46.1℃) (less than 120°F)
A teen mom asks the discharge nurse if it is okay to sleep in bed with her baby. She says her mom always did it with her siblings and it seemed okay. How should the nurse respond?
• "Baby can sleep in your room in an infant crib, but not in an adult bed."
A nurse is conducting a class for new mothers about infants and nutrition. One of the women asks, "What is the best nutrition for my 3-month-old infant?" Which response by the nurse would be most appropriate?
• "Human milk is the best nutrition for your child"
The infant weighs 6 lb 8 oz (2,912 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 4 months?
• 13 lb (5.9 kg)
A mother calls the clinic every couple of weeks concerned that her infant is not developing appropriately. What would be an appropriate nursing diagnosis for the nurse to assign to this client?
• Deficient knowledge related to normal infant growth and development
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."
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."
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?
• "My husband gave the baby a special bear that I will place in the crib."
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?
• "The cereal should be a fairly thin consistency at first."
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 palmar grasp."
A home visit nurse is providing health promotion on safety to a family of a 1-week-old infant. Which of the following statements by the parents indicates the need for further teaching?
• "We will position our infant on his side for sleeping."
A mother takes her 4-month-old to the doctor for a visit. She asks the nurse what type of baby cereal she should buy now that her child is starting solid foods. How should the nurse respond?
• "You should buy rice cereal."
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 this child at the age of 6 months?
• 27.5 in. (69.9 cm) Gain 1/2 to 1 inch for first 6 months By 12 months: length increased by 50 percent
The mother of a 16-month-old infant comes into the clinic and asks the nurse, "When will my baby play with toys by moving them from one hand to the other?" The nurse's response is based on knowledge that transferring objects from one hand to the other is normally accomplished by what age?
• 28 weeks
In working with infants, the nurse would expect the posterior fontanel to be closed in an infant who is which age?
• 3 months
The mother of a 4-month-old infant is working with the nurse to schedule well-child visits for her son. The mother would expect to schedule the next visit for her son at which age?
• 6 months routine schedule: 1 week, 1, 2 ,4, 6, 9, 12 months
When a cup is introduced to infants, the introduction of fruit juice may follow. What type of juice would be appropriate for an infant?
• Apple juice
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
A new mother asks for advice from the nurse about bathing her infant. Which of the following should the nurse tell her?
• Be sure to wash the infant's face, hands, and diaper area daily
A 6-month-old girl weighs 14.7 pounds (6.7 kg) during a scheduled check-up. Her birth weight was 8 pounds (3.6 kg). What is the priority nursing intervention?
• Discussing the child's feeding patterns
Which milestone would the nurse expect an infant to accomplish by 8 months of age?
• Sitting without support
If the infant is following a normal pattern of dentition, the child would most likely have how many teeth by the age of 14 months?
• Six to 12 teeth
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.
The nurse is assessing a 4-month-old infant during a scheduled visit. Which findings might suggest a developmental problem?
• The child does not vocally respond to voices.
A 12-month-old seen at a walk-in clinic weighed 8 pounds 4 ounces (3.75 kg) at birth. Weight now is 20 pounds 8 ounces (9.3 kg). The nurse determines:
• The child weighs less than expected for age.
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.
In observing an infant who is 6 months of age, which fine motor skill would the infant have most recently attained?
• The infant can hold a bottle. Question 2
The nurse in a community clinic is assessing a 4-week-old infant. The mother asks if the infant is developing normally. The nurse refers to which finding as suggestive of normal development in infants from birth to 4 weeks of age?
• The infant raises head and chest while on stomach
The nurse is assessing development of a 4-month-old boy during a well-child visit. Which observation needs further investigation?
• The infant responds to his mother when he sees her but not at other times when she is near.
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
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.
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.
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
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
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 around 4 months
