Chapter 15: Care of Newborn/Infant
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? "You need to renew this immunization every 10 years." "The 'T' stands for tuberculosis." "Bring her back for the second dose when she is 4 months old." "There are no side effects from this vaccine."
"Bring her back for the second dose when she is 4 months old." Explanation: DTaP is given as a series of five injections—at 2, 4, and 6 months; between 15 and 18 months; and between 4 and 6 years. A TdaP booster is needed by 11 to 12 years. There are common side effects such as fever and redness and swelling at the injection site as well as other less common reactions such as seizures. The "T" in the vaccine stands for tetanus
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 the infant at the age of 6 months? 29 in (74 cm) 27.5 in (70 cm) 30.5 in (77.5 cm) 32 in (81 cm)
27.5 in (70 cm) Explanation: Infants gain about 0.5 to 1 in (1.25 to 2.5 cm) in length for each of the first 6 months of life. Therefore, a 21.5-in (54.6-cm) infant adding 6 in (15 cm) of growth would be 27.5 in (70 cm). Infants grow the fastest during the first 6 months of life and slow down the second 6 months. By 12 months of age, the infant's length has increased by 50%, making this infant 32 in (81 cm) at 1 year old
The nurse is observing a 6-month-old boy for developmental progress. For which typical milestone should the nurse look? Puts down a little ball to pick up a stuffed toy. Picks up an object using his thumb and fingertips. Enjoys hitting a plastic bowl with a large spoon. Shifts a toy to his left hand and reaches for another.
Puts down a little ball to pick up a stuffed toy. Explanation: At 6 months of age, the child is able to put down one toy to pick up another. He will be able to shift a toy to his left hand to reach for another with his right hand by 7 months. He will pick up an object with his thumb and fingertips at 8 months, and he will enjoy hitting a plastic bowl with a large spoon at 9 months
When children are not able to communicate pain verbally, the nurse can use a behavioral assessment. The nurse knows that this assessment will least likely include: cry patterns. facial expressions. sleep patterns. body movements.
sleep patterns. Explanation: Cry patterns, facial expressions, and body movements are all part of the behavioral assessment for children who are not able to self-report the pain experience. Sleep may be used as a coping mechanism for pain and therefore not be an indicator that the child has obtained relief from pain
In working with infants, the nurse would expect the posterior fontanel to be closed in an infant who is which age? 3 weeks 6 weeks 3 months 1 month
3 months Explanation: The posterior fontanel is usually closed by the second or third month of life
Blood pressure monitoring becomes part of the routine health assessment at what age and older? 3 years 1 year 2 years birth 4 years
3 years Explanation: Blood pressure monitoring becomes part of the routine health exam at age 3
The nurse is examining an infant who is 4 days old. The nurse puts the infant on the back, supporting the weight of the infant by the arms, without using a lifting motion. The nurse then releases the arms suddenly. The nurse is assessing which newborn reflex? Moro Tonic neck Palmar grasp Babinski
Moro Explanation: The Moro reflex should initially elicit a startle response. By putting the infant on the back, while supporting the weight of the infant by the arms without using a lifting motion and then releasing the arms suddenly, the infant should throw the arms outward and flex the knees; the arms then return to the chest. The fingers also spread to form a C. The Babinski reflex is tested through stimulating the foot/toes, the palmar reflex through the hand/fingers, and the tonic neck by turning the infant's head to one side to elicit extension of the extremities on the same side and flexion on the opposite sid
When assessing the vision of a 2-month-old, what would the nurse use? green and yellow letters gray and blue animal drawings black-and-white checkerboard red and blue circles
black-and-white checkerboard Explanation: For infants younger than 6 months of age, objects such as a black-and-white checkerboard or concentric circles are best because an infant's vision is more attuned to these high-contrast patterns than to colors. High-contrast animal figures such as pandas or Dalmatians also work well
The student nurse asks the nursing instructor why nurses must be adept at understanding normal growth and development in children when providing care. How should the nursing instructor respond? "The nurse must understand normal development in order to measure the child's height and weight accurately." "If a nurse understands normal growth and development, he or she will be able to identify normal milestones in children." "Understanding normal growth and development is vital because it allows the nurse to administer the correct doses of medication to children." "By knowing normal growth and development, the nurse is able to identify problems in growth and development."
"By knowing normal growth and development, the nurse is able to identify problems in growth and development." Explanation: The nurse must understand normal growth and development in order to identify children who are not meeting milestones. A child meeting milestones does not need further intervention. Understanding normal growth and development is important in applying the assessment findings when measuring height and weight of children, but will not assure the procedure is completed properly. Administering the correct dose of medication is vital and involves accurate knowledge of the medication and dosage
When performing neurological reflexes on the infant, which primitive reflex will be present longest? step rooting Moro Babinski
Babinski Explanation: Primitive reflexes are subcortical and involve a whole-body response. Selected primitive reflexes present at birth include Moro, root, suck, asymmetric tonic neck, plantar and palmar grasp, step, and Babinski. Except for the Babinski, which disappears around 1 year of age, these primitive reflexes diminish over the first few months of life, giving way to protective reflexes
A new parent asks the nurse what she should look for when the baby starts to teethe. What should the nurse explain to the parent? The child will be constipated for 2 days. The child will not play or eat for 2 days. The child's gum line will be tender. The child will have a high temperature.
The child's gum line will be tender. Explanation: 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
When administering medications to an infant, what information will the nurse 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 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.
The oral medication should be directed toward the side of the mouth when using a syringe or dropper. Explanation: A syringe or dropper should be directed toward the side of the mouth with the infant in the upright position when administering an oral medication. The other choices would be inappropriate and may result in the child not receiving the full dose
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 3-year-old born at 29 weeks' gestation the 4-year-old twins born at 26 weeks' gestation the 24-month-old born at 28 weeks' gestation the 4-year-old born at 24 weeks' gestation
the 24-month-old born at 28 weeks' gestation Correct response: the 24-month-old born at 28 weeks' gestation Explanation: 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 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 crying every time someone picks her up." "She is so quiet today; that is not like her." "She is still sleeping; I guess she is worn out." "She has been a chatterbox and smiles just like her brother."
"She has been a chatterbox and smiles just like her brother. The best time to feed an infant is when the child is in the active alert state. This infant is talking and smiling, which shows she is calm and actively awake. In the active alert state the infant has normal respirations, limited movement, and eyes that are bright and shiny and attentive. The other choices put the infant in a crying state, quiet alert or deep sleep, or drowsing. These stages are not optimal for interacting with the child.
The nurse is beginning the examination of a 4-month-old infant. She takes the infant from the mother's arms to do the exam. Where should the nurse place the infant for the exam? in the crib on the infant's back in the nurse's own arms in the child treatment room in the crib facing the mom
in the crib facing the mom Explanation: When performing an exam on an infant, the nurse should place the infant in a position so that the parent is in view at all times. This is supportive and comforting to the infant. The other choices do not keep the parent in view
A 6-month-old infant is admitted to the hospital because of a fever. When the nurse obtains a health history, what data would be obtained first? Details about the fever Review of systems History of past illnesses Family profile
Details about the fever Explanation: When the child has an acute problem, it is important to first obtain the chief complaint. This is the reason the child is brought to the health care provider. The nurse would then ask further questions about the onset, the duration, the characteristics and the course of the problem. The family history, history of past illnesses, and a review of the systems would come later in the process of obtaining the health history.
The nurse is discussing medications to be given to a child who has been diagnosed with oral candidiasis (thrush). Which medication would most likely be prescribed for the child? aspirin nystatin ampicillin acetaminophen
nystatin Explanation: Application of nystatin to the oral lesions every 6 hours is an effective treatment for oral candidiasis (thrush). Treatment for diaper rash caused by Candida albicans is nystatin ointment or cream applied to the affected area
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 with the tape touching just below the eyes. Expect the head circumference and the chest circumference measurements to be equal up to the age of 6 years. Place the tape measure around the head just above the eyebrows. Measure the head circumference routinely on children up to the age of 6 years.
Place the tape measure around the head just above the eyebrows. Explanation: The head circumference is measured routinely in children to the age of 2 or 3 years, or in any child with a neurologic concern. Place a paper or plastic tape measure around the largest part of the head just above the eyebrows and around the most prominent part of the back of the head. During childhood the chest exceeds the head circumference by 2 to 3 inches.
The nurse is reviewing the health history of an infant who is demonstrating developmental delays. Which finding would be considered a possible risk factor? gestational age 35 weeks paternal history of alcohol use disorder being raised by a single adolescent mom birth weight of 1,950 grams
being raised by a single adolescent mom Explanation: Parental factors can be associated with developmental delays in the child. Being raised by a single parent or a parent having less than a high school education are associated with delays in the child. Birth weight less than 1500 grams is associated with delays. Children born at 33 weeks' gestation or less are at an increased risk for developmental delays
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 the expected amount for age. the child weighs less than expected for age. the weight assessment is blatantly inaccurate. the child weighs more than expected for age.
the child weighs less than expected for age. Explanation: Birth weight should triple by 12 months. The child should weigh near 24 pounds 12 ounces (11250 g). The child is underweight for age.
The nurse is assessing the 18-month-old infant. The nurse notes the anterior fontanel (fontanelle) has closed. What initial action by the nurse is indicated? Document the findings as normal. Review the birth records of the infant to see if there were any other anomalies. Measure the infant's head circumference. Notify the infant's health care provider.
Document the findings as normal. Explanation: The anterior fontanel (fontanelle) most often closes between 12 and 24 months of age. The closure of the fontanel (fontanelle) at 18 months of age does not signal any health issues for the infant.
The best way for an infant's parent to help the child complete the developmental task of the first year is to: keep the infant stimulated with many toys. expose the infant to many caregivers to help the infant learn variability. respond to the infant consistently. talk to the infant at a special time each day.
respond to the infant consistently. Explanation: The developmental task of an infant is gaining a sense of trust. The infant develops this sense from the caretakers who respond to the child's needs, such as feeding, changing diapers, being held. It is a continuous process. 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. An infant is too young to have variability in caretakers. This causes mistrust. The parents or caretakers do not need a special time to talk to the infant each day. It should be done with each interaction. Providing too much stimulus before the infant develops gross motor skills causes frustration from the child and not enjoyment
The nurse is assessing a newborn child. The mother asks why the feet are blue. What is the best response by the nurse? "When a foot or hand is blue, it's called peripheral cyanosis. Peripheral cyanosis is not normal in newborns." "Blueness in the feet of a newborn is called pallor. This is a normal finding in babies up to several days old." "A blue tint to skin means that there is a lack of oxygen. I will need to notify the physician of this immediately." "Blueness of hands and feet is a common finding in newborns. It is a result of their circulatory system switching from being in the womb to life outside the mom's body."
"Blueness of hands and feet is a common finding in newborns. It is a result of their circulatory system switching from being in the womb to life outside the mom's body." Explanation: Blueness of the hands and feet, known as acrocyanosis, is normal in babies up to several days of age and results from an immature circulatory system completing the switch from fetal to extrauterine life. Although blueness in hands and feet may indicate a lack of oxygen and may be called peripheral cyanosis, acrocyanosis is a normal finding in a newborn. Pallor is defined as paleness, not blueness of skin
The parents of a newborn are deciding if they want their newborn circumcised. The parents ask the nurse if their newborn can feel any pain during the procedure. How should the nurse respond? "I am sure your newborn is too young to experience any pain." "Your newborn's nervous system is not developed enough to experience pain." "Although it is possible for your newborn to experience pain, it is very unlikely for the pain to be intense." "It is hard to know for sure, but research shows that it is possible for newborns to experience pain."
"It is hard to know for sure, but research shows that it is possible for newborns to experience pain." Explanation: Research has demonstrated that the nervous system structures needed for pain impulse transmission and perception are present before birth (American Medical Association, 2013). Therefore, children of any age, including preterm newborns, are capable of experiencing pain
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? "Once he gets used to the cereal, then we'll try giving him a cup." "The cereal should be a fairly thin consistency at first." "I'll start with baby oatmeal cereal mixed with low-fat milk." "I can puree the meat that we are eating to give to my baby."
"The cereal should be a fairly thin consistency at first." Explanation: Iron-fortified rice cereal mixed with a small amount of formula or breast milk to a fairly thin consistency is typically the first solid food used. As the infant gets older, a thicker consistency is appropriate. Strained, pureed, or mashed meats may be introduced at 10 to 12 months of age. A cup is typically introduced at 6 to 8 months of age regardless of what or how much solid food is being consumed
What information would the nurse include when teaching the parents of an infant about colic? Symptoms will decrease if the infant is laid on the back after feedings. Formula intake should be doubled to keep the infant from losing weight. The infant will need future follow-up for a "nervous" bowel. Colic symptoms will probably fade at 3 months of age.
Colic symptoms will probably fade at 3 months of age. Explanation: Colic is defined as inconsolable crying that lasts 3 hours or longer per day and which it has no physical cause. Colic symptoms typically fade around 3 months of age. This is an age when infants are better able to console themselves. Colic can be very stressful for parents and lead to sleep deprivation. Many infants need to be carried at all times to reduce crying. Some do well with non-nutritive sucking and others need white noise or motion to help them soothe. Because colic has no physical cause, telling the parents about follow up for "nervous stomach" is not necessary. The infant should be placed in a position of comfort to reduce the crying. Every infant has his or her own position that helps; don't just place the infant on his or her back. Doubling up the formula will not help colic and may actually cause more problems because it can cause abdominal pain and increased weight gain
A nurse is taking a history at the office of a 3-month-old infant with colic. The parents are upset and frustrated. Which of the following responses by the nurse is most appropriate? "You are not bad parents." "Here is a pamphlet on normal sleep patterns for a 3-month-old infant." "You as parents should practice relaxation exercises." "Let me show you how to soothe your infant."
You are not bad parents." Explanation: Crying is a normal aspect of infant development and includes increased periods of fussiness during the day, occurring approximately 2 weeks of age through 3 to 4 months of age. If the infant has a "fussy" period lasting more than 3 hours, and the infant is inconsolable and draws the legs up with grimacing and gas, then he/she may have colic. This can be caused by gastrointestinal pain. The interventions for infant colic are to be supportive of parents and provide the infant with a soothing and resting environment. Handing the parents a pamphlet on normal sleep patterns will not help their frustration. Showing them how to soothe their infant may make them feel inadequate. Telling them they should relax is not appropriate. Reminding that they are not doing anything wrong and are not bad parents may help them to relax.
A mother of a 9-month-old 18-pound (8.2 kg) infant asks the nurse about choosing the best car seat. What should the nurse recommend? a rear-facing 5-point harness restraint a forward-facing convertible booster a forward-facing 5-point harness restraint a rear-facing booster seat
a rear-facing 5-point harness restraint Explanation: An infant until 2 years of age should be in a rear-facing car seat. The 5-point harness seat is made for children up to 40 pounds (18 kilograms) and the booster seat for children from 40 to 80 pounds (18 to 36 kilograms)
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? "Iron-fortified formula is necessary for the infant's growth." "Experts recommend soy milk as the preferred food." "Rice cereal is the best because allergy risk is low. " "Human milk is the best nutrition for your child"
"Human milk is the best nutrition for your child" Explanation: Human milk provides optimal nutritional support for a newborn and has recognized prebiotic and anti-inflammatory effects that enhance biological wellness for the child. Ingestion of human milk is known to aid the newborn's immature immune system. Breastfeeding is the feeding method most encouraged by health care providers today, resulting from the nutritional composition of the milk, the additional immunity it provides the infant in the form of antibodies, and the fact that it has the most easily digestible form of protein. Human milk is readily available, inexpensive, and encourages bonding between the mother and infant. The American Academy of Pediatrics (2005a) recommends breastfeeding exclusively (no supplemental formulas or baby foods) for approximately the first 6 months and supports continued breastfeeding after foods are introduced to serve as the child's milk source for the entire first year as long as it is mutually desired by the infant and the mother. Parents should not offer low-iron milk (e.g., cow, goat, soy) to their child until the child is at least 12 months old. Cow's milk or goat's milk can contribute to anemia because both are deficient in iron. Infants should also never receive low-fat or nonfat milk because these types of milk do not have the fat, calories, or iron needed to support the rapid growth and development that occurs at this age
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 popcorn." "I can feed our baby lollipops." "I can feed our baby Cheerios." "I can feed our baby raisins."
"I can feed our baby Cheerios." Explanation: Cheerios are a good choice for finger-foods to promote finger-grasp fine motor coordination and self-feeding. Ten to 12 months is a good age to promote self-eating as infants move into mostly solid foods. Popcorn, raisins, and lollipops are choking hazard foods for infants at this age
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? 9 months old 8 months old 7 months old 6 months old
7 months old Explanation: 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 calls a clinic nurse to ask if her infant born prematurely should receive the seasonal influenza vaccine. The nurse's next question should be: "Did your baby have any respiratory problems?" "Does your baby have any allergies?" "How old is your baby?" "How premature was your baby?"
How old is your baby?" Explanation: Flu vaccine and all other vaccines are administered according to chronological age. Flu vaccine is recommended for all infants at 6 months of age and given yearly thereafter. An underlying respiratory problem makes flu vaccine important. Awareness of allergies is also necessary, but the first question is chronological age to determine if the infant is old enough to receive the vaccine
Which milestone would the nurse expect an infant to accomplish by 8 months of age? Pulling self to a standing position Sitting without support Being able to sit from a standing position Creeping on all fours
Sitting without support Explanation: Physical development of infants occurs in a cephalocaudal fashion. That means they must learn to control and lift their heads first. This is followed by the ability to turn over. Once this occurs the remainder of development occurs quickly. Most infants are able to sit unsupported by 8 months. They are able to creep at 9 months and pull to a standing position by 10 months. At 12 months the infant is able to sit from a standing position and is learning to walk
The nurse is assessing an infant at the 6-month well-baby check-up. The nurse notes that at birth the baby weighed 8 lb (3600 g) and was 20 in (50.8 cm) in length. Which finding is consistent with the normal infant growth and development? weight of 20 lb (9100 g) and length of 30 in (76.2 cm) weight of 14 lb (6400 g) and length of 24 in (61.0 cm) weight of 18 lb (8200 g) and length of 28 in (71.1 cm) weight of 16 lb (7300 g) and length of 26 in (66.0 cm)
weight of 16 lb (7300 g) and length of 26 in (66.0 cm) Explanation: The average newborn weighs 7.5 lb (3400 kg) at birth. Most infants double their birth weight at 4 to 5 months and will triple by the time they are 1 year old. If this infant was 8 lb (3600 kg) at birth, then it is most likely now 16 lb (7300 g). The average newborn is 20 in (50 cm) long at birth. They grow more quickly in length over the first 6 months, than during the second 6 months. By 12 months of age, the infant's length has increase by 50%. At 1 year, this infant will most likely be 30 in (76.2 cm) in length; however, since most of the growth occurs in the first 6 months, it is possible for the infant to grow an additional 6 in (15 cm) during that time
A nurse is providing anticipatory guidance to new parents of an infant. Which information would be most important to stress with the parents to promote the infant's development of trust? "Each day at a special time, talk to your baby." "Try to have many caregivers caring for the baby so they learn variability." "Stimulating your baby with many toys is key." "It's important to respond to the baby's needs consistently."
"It's important to respond to the baby's needs consistently." Explanation: 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 exposure to many caregivers will not help the child develop a sense of trust
The nurse is giving discharge instructions to a mother of a 3-month-old infant who will be receiving oral medication at home. Which of the following would the nurse include in the teaching plan? Hold the infant's nose while squirting the medication into the mouth, directly at the back of his throat. Mix the oral medication in a small amount of formula or breast milk in a bottle and then give it to your baby. Lay the infant in a crib and use a syringe to squirt a small amount of medicine beside the tongue a little at a time. Give the medication with a syringe and squirt a small amount at a time beside the tongue while holding the infant upright.
Give the medication with a syringe and squirt a small amount at a time beside the tongue while holding the infant upright. Explanation: Infants should be given oral medications with a syringe. Squirt a small amount at a time onto the side of the tongue while holding the infant upright in order to prevent aspiration. Medications should never be mixed with an infant's formula or breast milk since this is their primary source of nutrition and the infant could develop an aversion to it. Infants should be positioned upright or with the head of the bed elevated when giving oral medications. Infants are obligatory nose breathers therefore holding shut the nose is contraindicated. Medication should be squirted beside the tongue
The nurse is observing a novice nurse measure the head circumference of a 9-month-old infant. The nurse determines that the novice nurse is performing the skill correctly based on which action? Measuring from the hairline in front to the hairline in back. Measuring from the middle of the forehead through the parietal prominences. Measuring from the center of the forehead to the posterior fontanel (fontanelle). Measuring from above the eyebrows through the prominent part of the occiput
Measuring from above the eyebrows through the prominent part of the occiput. Explanation: Head circumference is measured by placing a tape measure around an infant's forehead just above the eyebrows and around the most prominent portion of the back of the head or the occipital prominence. Head circumference is not measured using the hairline, parietal prominences, nor posterior fontanel (fontanelle)
The nurse is examining an infant who is 4 days old. The nurse puts the infant in a semi-upright position and lets the head fall back (with immediate support). What infant reflex is the nurse testing? root Babinski Moro palmar grasp
Moro Explanation: The Moro reflex is stimulated when the infant is semi-upright and the head falls backward. When this happens, the infant responds with symmetrical abduction and extension of the arms, flexion of the thumb, and flexion of the upper limbs. This response should not persist after 4 months of age. The Babinski sign is tested through stimulating the foot/toes. The palmar reflex is tested through the hand/fingers. The root reflex is tested through touch on the corner of the mouth
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 sit steadily at 4 months; this infant is normal. Most infants sit steadily at 3 months; this infant is slightly delayed. Sitting ability and the age of first tooth eruption are correlated. Most infants do not sit steadily until 8 months; this infant is normal.
Most infants do not sit steadily until 8 months; this infant is normal. Explanation: At 3 months of age the infant should be able to raise the head about 45 degrees when in the prone position. The infant does yet have the developmental skills for sitting. Most infants are unable to sit steadily until 8 months of age. Gross motor skill development does not correlate with tooth eruption. The nurse should reassure the parent that this infant is on tract developmentally
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? Praise the infant when a new milestone is reached. Respond promptly when the infant cries. Read age-appropriate books to the infant daily. Appropriately enunciate words when speaking to the infant.
Respond promptly when the infant cries. Explanation: The developmental task of the infant year, according to Erikson, is to gain a sense of trust. This can be accomplished by promptly meeting the infant's needs during the first year of life. If the infant does not learn to trust, mistrust will develop. Praising will help meet the future developmental tasks of the child. Reading books and appropriately enunciating words will aid in the infant's language development.
A 2-week-old infant responds to a bell during an initial health supervision examination. The infant's records do not show that a newborn hearing screening was done. Which action will the nurse take? Ask the parent to observe for signs that the infant is not hearing well. Screen again with the bell at the 2-month-old health supervision visit. Schedule the infant for a newborn hearing screening. Do nothing because responding to the bell proves the infant does not have a hearing deficit.
Schedule the infant for a newborn hearing screening. Explanation: Guidelines for infant hearing screening recommend universal screening with an auditory brain stem response (ABR) or evoked otoacoustic emissions (EOAE) test by 1 month of age. All the other answers rely on behavioral observation. Studies have shown that behavioral observations are not a reliable method of screening for hearing loss
Infants or children receiving antibiotics may develop oral candidiasis (thrush). Which finding suggests that an infant has thrush? diffuse buccal erythema without discharge presence of a white membrane on tongue mucopurulent sputum oral pruritus
presence of a white membrane on tongue Explanation: A fungal infection, oral candidiasis presents with a white membrane on the tongue or mucus membrane that does not scrape away
To obtain an accurate heart rate in an infant, what would be most important for the nurse to do? Use an electronic stethoscope. Take a radial pulse. Take the apical pulse. Count the pulse rate for 30 seconds.
Take the apical pulse. Explanation: Taking the apical pulse with a stethoscope and counting the rate for a full minute is the most accurate way to obtain the heart rate on an infant. The radial pulse should only be taken with older children, as it is difficult to palpate accurately in children younger than 2 years of age because the blood vessels lay close to the skin surface and are easily obliterated. An electronic stethoscope is not necessary to listen to heart sounds and count an apical pulse
A nurse is collecting weight on a 6-month-old infant. The weight was 14 lbs 3 oz. The mother states that the infant's birth weight was 8 lbs 8 oz. What is the nurse's assessment of this data? The weight is too much for age. The weight is appropriate for age. It cannot be determined. The weight is too little for age.
The weight is too little for age. Explanation: By 6 months of age the infant should double its birth weight. The nurse may need to further assess the infant's health status and nutritional status
A parent must administer a medication in syrup form to a 2-month-old infant. The nurse suggests: placing the syrup in a small amount of rice cereal. using a measured medicine spoon. placing the syrup in an medicine syringe. mixing the syrup in a small amount of formula.
placing the syrup in an medicine syringe. Explanation: 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
