232 chapter 3
The nurse is preparing a list of abilities of 10-month-olds to use in teaching a parenting group. Which ability should appear at this age?
Cruises around furniture Rationale:At 10 months, this ability appears and is practiced often in preparation for later independent walking. All the rest of the skills take an additional 2 months to develop and appear around age 1 year.
At birth the newborn's head and chest circumference were measured. The nurse knows that the head should be about:
1 in larger than the chest. Rationale:The head is about 1 inch (2.5 cm) larger than the chest and will grow rapidly during the first 6 months. Chest circumference is not routinely measured after the newborn period.
The infant in the exam room has these signs and symptoms. Which will the nurse attribute to teething? (Select all that apply.)
Drooling and biting, Increased sucking on hands, Irritability and awakening from sleep, Refusing to eat Rationale:Fever and diarrhea are considered signs of illness, not teething. The others are typical of teething.
The nurse is promoting a healthy diet to the parent of a 6-month-old infant. What action would have the most effect on the infant's neurologic development?
Promoting continuation of breastfeeding Rationale:Continuing to breastfeed ensures the proper level of nutritional fat for myelination of the nervous system. Having adequate dietary iron would help prevent anemia as the stores from fetal development are depleted. Promoting increased intake of solid foods is not necessary at 6 months and may diminish the amount of breast milk consumed. Fruit juice in the diet is not recommended. Fruits provide more nutrition and will soon be gradually added to the infant's diet.
A 12-month-old seen at a walk-in clinic weighed 8 lb 4 oz (3.75 kg) at birth. Weight now is 20 lb 8 oz (9.3 kg). The nurse determines:
The child weighs less than expected for age. Rationale:Birth weight should triple by 12 months. The child should weigh near 24 lb 12 oz (11.25 kg). The child is underweight for age.
A 5-month-old infant being assessed was born at 32 weeks. The nurse doing the well-child check-up should compare the baby to what norms?
The development of a 3-month-old Rationale:The infant was born 8 weeks early. Two months are subtracted from the present age of 5 months. Both growth and development should be assessed using 3-month norms.
The nurse is assessing development of a 4-month-old infant during a well-child visit. Which observation needs further investigation?
The infant responds to the parent when the infant sees him or her but not at other times when the parent is near. Rationale:If the infant does not respond to the parent's voice, it could indicate hearing loss. Infants recognize parents' voices from 1 month of age. It is normal for the infant to turn the head in the direction of a squeak toy, to focus visually on near or high-contrast objects, and to make babbling sounds but no words by this age. Infants develop a social smile at 2 months.
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 the crib at the last place the infant saw it. Rationale:Looking for the toy where it was last seen indicates object permanence. The infant knows the object still exists even though the infant cannot see it. All the rest of the infant's behaviors show use of the senses and motor activity but do not illustrate object permanence.
The nurse pulls the 5-month-old to sitting position from supine and notes head lag. The nurse's response is to:
refer the infant for developmental and/or neurologic evaluation. Rationale:There should be no head lag by 4 months. Head lag in the 5-month-old may indicate motor or neurologic problems and needs immediate follow-up. All other nursing actions indicate failure to recognize the problem.
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. Rationale:This primitive (not protective) reflex should be present at birth and disappear around age 4 months.
The nurse is teaching the parent of a 5-month-old boy who is concerned about thumb sucking. What should be included in the teaching plan? (Select all that apply.)
Advising the parent this behavior is a form of self-comfort, Telling the parent this behavior usually decreases by 6 to 9 months of age, Informing the parent that thumb sucking occurs more often during periods of stress, Assuring the parent this behavior won't cause malocclusion Rationale:All are accurate and should help the parent better understand and accept the behavior.
Parents state they are "worn out" at their child's 6-month check-up because their child awakens each night and cries. The nurse suggests which measures?
Establish a quieting ritual before bed. Rationale:Bedtime rituals help both promote sleep. During awakenings, the parents should interact with the child, but minimize attention and stimulation. Adding rice cereal to bottles does not promote sleeping through the night and isn't recommended. Rocking the child to sleep and then placing them into the crib does not teach the child to self-soothe and fall asleep independently.
The nurse is conducting a physical examination of a 5-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). Rationale:The tonic neck reflex normally disappears by age 4 months, the palmar grasp reflex by age 6 months, and the Babinski reflex (fanning of toes when sole of foot stroked) by 12 months. Retaining these primitive reflexes may indicate a neurologic abnormality. The anterior fontanel, which remains open for brain growth, closes between 12 and 18 months of age.
A parent is discussing the 10-month-old child with the nurse. Which comment indicates a need for teaching?
"My child loves being in the walker and 'zips' around the house." Rationale:Walkers are safety hazards and not recommended by the American Academy of Pediatrics. They cause falls plus promote the ability to reach items on surfaces otherwise inaccessible. The other comments are age appropriate and acceptable practice.
The parent of an infant questions the nurse about the baby's teething. The nurse provides client education. Which statement by the parent indicates understanding of the information provided?
"The first teeth that will likely appear are the lower incisors." Rationale:Teeth will begin erupting between 6 and 8 months. Traditionally, the first teeth to erupt will be the lower incisors, followed by the upper incisors. By the age of 12 months, the infant will have between 4 and 8 teeth, if progressing normally.
A young breastfeeding parent calls the telephone nurse because the parent is concerned about the 3-month-old's stools. Which information indicates a possible problem?
"The stools are foamy and smell terrible." Rationale:This may indicate a digestive problem or illness. The health care provider or nurse practitioner should be contacted. All the other statements describe normal stooling.
Place these primitive protective reflexes of infancy in the order in which they will disappear as the child matures.
1)Babinski 2)Root 3)Step 4)Plantar 5)Moro The step reflex will disappear at 4 to 8 weeks; the root reflex at 3 months; the Moro reflex at 4 months; the plantar reflex at 9 months; and the Babinski reflex by 12 months.
The nurse is examining an 8-month-old child for appropriate development during a regular check-up. Which observation points to a developmental risk?
Uses only the left hand to grasp Rationale: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 helping the parent of a 5-month-old infant 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 Rationale: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 teaching the parent of a 2-month-old infant about the social and emotional developments that will occur in the next 8 weeks. Which behavior is most likely to occur?
Mimicking parent's facial expressions Rationale:Infants will mimic the facial expressions of their parents when they are 3 to 4 months old. Becoming clingy around strangers probably won't occur until the child reaches 6 months. Engaging in peek-a-boo becomes fun between 6 and 8 months. Crying when the parent is out of sight indicates separation anxiety and is common after 6 to 8 months of age.
The nurse is providing anticipatory guidance regarding the respiratory development of a 4-week-old infant for the parent. Which action is accurate?
Explaining to the parent the risk for infection is high due to the lack of antibodies Rationale:Attributing frequent infections to a lack of antibodies is accurate. The infant lacks IgA in the mucosal lining of the upper respiratory tract. The infant's respiratory rate drops to 20 to 30 breaths per minute by the end of the first year. Abdominal breathing persists until 6 to 12 years of age. The respiratory system matures by age 7 years.
What feeding practice used by the parents of an 8-month-old should the nurse discourage?
Placing all liquids given the child in a "no spill" sippy cup Rationale:No spill sippy cups promote sucking rather than teach cup drinking. Reserve these for times avoiding spills is essential. The other feeding practices are age appropriate and safe. Soft table and finger foods promote accepting new textures and self-feeding. Reoffering rejected food allows the child to accept it when ready. Including the infant at the family table provides for modeling of eating behaviors and socialization.
The parents of a 4-day-old infant report concern about the infant's weight loss. What is the best response by the nurse?
With appropriate nutrition weight gain will commence with a return to the birth weight within 2 weeks." Rationale:The average newborn weighs 7 lb 8 oz (3,400 g) at birth. Newborns lose up to 10% of their body weight over the first week of life. The average newborn then gains about 30 g per day and regains his or her birthweight by 10 to 14 days of age. Most infants double their birth weight by 4 months of age and triple their birth weight by the time they are 1 year old.
A parent mentioned to the nurse that the usually smiling, happy 8-month-old child was clingy and intensely serious when the grandparent visited from a distant city. The nurse explained the child was experiencing:
stranger anxiety. Rationale:Stranger anxiety occurs around 8 months and manifests as the parent described. This behavior indicates the infant sees himself as a separate person. The other options are incorrect and not related to social/emotional development.
The nurse is caring for a 5-week-old infant who is spitting up "all the time." This is the parent's first child. What should be the priority nursing intervention?
Observe the parent during feeding and burping the infant. Rationale:Assessing the parent's feeding and burping technique is the first nursing action needed. The parent may be overfeeding or inadequately burping the child. Recommending smaller and more frequent feedings would be determined by the assessment. Assuring the parent that some spitting up is normal and describing the capacity of the infant's stomach is helpful information but not the priority.
The nurse is performing an assessment on a 8-month-old infant. The infant's medical history notes that he was born at 32 weeks' gestation. The infant is progressing normally. At what adjusted age should the nurse expect the infant's developmental accomplishments?
The infant will most likely present with developmental skills consistent with a 6-month-old infant. Rationale:When assessing the growth and development of a premature infant, the nurse will use the infant's adjusted age to determine expected outcomes. To determine adjusted age, the nurse subtracts the number of weeks that the infant was premature from the infant's chronologic age. The infant who was born at 32 weeks' gestation was 8 weeks or 2 months premature. To determine the adjusted age, the nurse subtracts 2 months from the chronologic age of 8 months: 6 months.