Chapter 29: Nursing Care of a Family with an Infant

The nurse is assessing a 12-week-old infant in the clinic at a well-baby visit. Which assessment finding does the nurse predict to assess in this healthy infant?

*Smiles at significant others* By 12 weeks of age the infant smiles at their mother and significant others. The other choices are seen in the infant who is about 20 weeks of age.

A client who is breastfeeding asks the nurse if she can give the newborn a pacifier. Which nursing response is most appropriate?

*"It is recommended to wait until breastfeeding is well-established before introducing a pacifier."* It is recommended to wait to introduce a pacifier once breastfeeding is well-established, which can take about 1 month. This is to limit nipple confusion and promote an adequate milk supply. Stating other people have done this does not provide education to the client, nor does it address this specific client's situation. While the decision is up to the newborn's parents, this response does not address the client's concern. Requesting a lactation consultant come does not address the client at this moment. The nurse can provide education now, and also request the consultant for follow-up information.

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."* Iron-fortified oatmeal 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.

The nurse establishes the following plan of care based on the nursing diagnosis: Caregiver role strain related to infant crying throughout night as manifested by parents stating, "We are exhausted." Which nursing interventions are included in the plan of care? Select all that apply.

Establish a quieting ritual for infant before bed. Having one parent awake at a time with infant During night awakening, keep interactions minimal.

An 8-month-old child is diagnosed with a second ear infection and the father is concerned the infections are being caused by something he is doing or by something in the child's development. Which question should the nurse prioritize to collect more information to answer this father's questions?

*"Does the baby go to bed with a bottle of formula each night?"* In addition to nursing bottle caries, liquid from milk, formula, or juice can pool in the mouth and flow into the eustachian tube, causing otitis media if an infant falls asleep with a bottle. Teething and shampooing the scalp and hair would not be a factor in the development of ear infections. Vitamin C is a needed supplement for the infant who is fed home-prepared formula; it does not cause ear infections.

The nurse is reviewing the diet of an 8-month-old infant with the mother who reveals she has been using evaporated milk to make the formula. Which additional ingredient should the nurse ensure she is including in the formula?

*iron* Infants who are fed home-prepared formulas (based on evaporated milk) need supplemental vitamin C and iron. Evaporated milk has adequate amounts of vitamin D, which is unaffected by heat used in the preparation of formula. Calcium and vitamin E would not be a concern in this infant's formula.

When assessing a 6-month-old infant, which symptom will the nurse bring to the health care provider's attention?

*presence of Moro embrace reflex* It is important for the nurse to understand normal infant milestones and growth in order to ascertain abnormal findings. Moro embrace reflex should be absent at 4 to 5 months. Grasp reflex begins to fade at 2 months and should be absent at 3 months. A 4-month-old infant should be able to roll from back to side and balance the head when sitting.

The nurse is reinforcing teaching with a group of caregivers related to the nutritional needs of the infant. One caregiver asks why the 6-month-old infant needs to have solid foods when breast milk is such a good source of nutrition. What would be the best response by the nurse?

*"Milk will not fully provide the child's needs for iron, which is found in solid foods."* At about 4 to 6 months of age, the infant's milk consumption alone is not likely to be sufficient to meet caloric, protein, mineral, and vitamin needs. In particular, the infant's iron supply becomes low, and supplements of iron-rich foods are needed. It is also around 4 to 6 months when the infant is able to swallow solids effectively and has the necessary enzymes necessary to digest them. It is true that the child becomes interested in new skills, but this is not the primary rationale for introducing solids. Few parents will understand the "extrusion reflex" so using that term is not effective in teaching. The nurse should, however, describe the reflex to the parents. Breastfeeding does not become painful when the child develops teeth. Many mothers nurse for long after their infants develop teeth.

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?

*27.5 in (70 cm)* 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 caring for a 5-week-old infant who is spitting up "all the time." This is the mother's first child. What should be the priority nursing intervention?

*Observe the mother while she feeds and burps her infant.* Assessing the mother's feeding and burping technique is the first nursing action needed. The mother may be overfeeding or inadequately burping the child. Recommending smaller and more frequent feedings would be determined by the assessment. Assuring the mother 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 assessing a 6-month-old infant in the clinic. Which characteristic represents normal language development for this age?

*babbling* Cooing begins in the first 4 weeks of life, productions of noises when spoken to and laughing out loud are seen later than 6 months of age. Infants begin to babble around 6 months of age.

The nurse is helping the mother of a 5-month-old boy 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* 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 caregivers of an infant state that their child cries when her mother leaves for even a short amount of time. What might the nurse suggest as a way to console the infant and develop a sense of security when the child's primary caregiver is out of sight?

*Play peek-a-boo with the child when happy.* For the infant, self-assurance is necessary to confirm that objects and people do not cease to exist when out of sight. This is a learning experience on which the infant's entire attitude toward life depends. The ancient game of "peek-a-boo" is a universal example of this learning technique. It is also one of the joys of infancy as the child affirms the ability to control the disappearance and reappearance of self. In the same manner by which the infant affirms self-existence, she learns to confirm the existence of others, even when they are temporarily out of sight.

The nurse is conducting a physical examination of an 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 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.

The nurse is examining an 8-month-old girl for appropriate development during a regular check-up. Which observation points to a developmental risk?

*Uses only the left hand to grasp* 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 in a community clinic is caring for a 6-month-old infant and parent. Which nursing intervention is priority?

*monitoring the infant's weight and height* Monitoring the infant's weight and height is the priority intervention. Ongoing assessments of growth are important so that too-rapid or inadequate growth can be identified early. With early identification, the cause can be diagnosed and the potential for further appropriate growth maximized. Encouraging a more frequent feeding schedule, obtaining the infant's current feeding pattern, and recommending higher-calorie solid foods are interventions that would be used should assessment show that the client's nutrition level does not meet body requirements.