Peds: PrepU Ch. 3
Which developmental milestone would the nurse expect an 11-month-old infant to have achieved?
Sitting independently Infants typically sit independently, without support, by age 8 months. Walking independently may be accomplished as late as age 15 months and still be within the normal range. Few infants walk independently by age 11 months. Building a tower of three or four blocks is a milestone of an 18-month-old. Turning a doorknob is a milestone of a 24-month-old.
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. 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.
A nurse is conducting an assessment of a 13-month-old. The mother notes that the infant cannot pull herself into a standing position. Which assessment should the nurse conduct to gather more information to report to the health care provider?
symmetry of gluteal skin folds assessment By assessing for symmetry of gluteal skin folds the nurse would be assessing for signs of developmental dysplasia of the hip. It is expected that by about 10 months of age infants can pull themselves into a standing position.
The nurse is educating the mother of a newborn about feeding practices. The nurse correctly advises the mother that:
the newborn's stomach can hold between one-half and 1 ounce. The capacity of the normal newborn's stomach is between one-half and one ounce. The recommended feeding plan is to use a demand schedule. Newborns may eat as often as 1.5 to 3 hours. Demand scheduled feedings are not associated with problems sleeping at night.
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. This primitive (not protective) reflex should be present at birth and disappear around age 4 months.
At what age would it be okay to introduce carrots to an infant's diet?
Solid food can be introduced at 4 to 6 months of age. The tongue extrusion reflex is present until the infant is 4 to 6 months of age. After this reflex disappears then solid food may be introduced. The infant's ability to swallow solid foods is not completely functional until this age nor are the enzymes present which are needed to process foods. The infant must be ready to handle spoon-feeding. By 7 months onward, the baby should be eating solid foods regularly and drinking from a cup in addition to breast or bottle feeds.
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 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 a 1-year-old at the well-child annual visit and notes the child is meeting the growth parameters. After noting the birth weight was 8 pounds (3.6 kg) and length was 20 inches (50.8 cm) long, which measurements would the nurse prepare to document for this visit?
24 pounds (10.8 kg) and 30 inches (75 cm) By 1 year of age, the infant should have tripled his or her birth weight and grown 10 to 12 inches (25 to 30 cm). If this infant was 8 pounds (3.6 kg) at birth, at 1 year, this child should weigh 24 pounds (8 x 3 = 24) and grown to 30 to 32 inches (20 + 10 to 12 = 30 to 32 inches). Most of the growing occurs during the first 6 months with the infant's birth weight doubling and height increasing about 6 inches (15 cm). Growth slows slightly during the second 6 months but is still rapid.
An infant has been brought to the clinic for a well-child check. The infant is 12 months of age. The child's birth weight was 6 pounds, 7 ounces. What is the anticipated weight for the child at this visit?
19 pounds, 5 ounces 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 9-month-old has been brought to the clinic for a well-child visit. The mother reports her son was born 6 weeks prematurely. During the data collection, the child's mother reports her son seems to be a few months "behind" what she recalls from her older children. What is the bestresponse by the nurse?
"Delays are normal when a child is premature." When infants are born prematurely delays may be noted. When assessing the growth and development of a premature infant, use the infant's adjusted age to determine expected outcomes. To determine adjusted age, subtract the number of weeks that the infant was premature from the infant's chronological age. Plot growth parameters and assess developmental milestones based on adjusted age. Delays will not necessarily be resolved by the age of 6 months. While the mother should talk with the physician about concerns, this is not the best initial response by the nurse.
The parents of an 8-month-old boy voice concern to the nurse that their child is not developing motor skills as he should. What question would be appropriate for the nurse to ask in determining if their fears are warranted?
"Does he move a toy back and forth from one hand to the other when you give it to him?" Transferring an object from one hand to the other is expected at 7 months of age, so this would be expected of an 8-month-old. The other options are not expected until later months, so questioning the parents about these skills would not help in determining if he was at the motor skill developmental level that should be expected.
A parent asks the nurse if her 2-month-old could have bananas yet. The nurse would respond and educate the parent on the nutrition stages of infants by which of these responses?
"In two months you can try bananas if you think she is ready." The nurse should choose this response because no solid foods are recommended for infants until 3 months of age. The age of 4 to 6 months is the age recommended to introduce solid foods. The other responses are the incorrect age or are letting the parent decide the appropriate answer.
What is the correct amount of wet diapers a mature infant should produce each day?
An infant should have 6 to 8 wet diapers/day. Urination occurs in the first 24 hours of life. A normal amount of urine is 200 to 300 ml/day as the infant matures. This amount is equal to 6 to 8 wet diapers/day. The infant should have an intake of between 140 to 160 ml/kg/day to be well hydrated and nourished. This amount of intake will produce the 6 to 8 diapers/day.
The student nurse is caring for a 2 1/2-week-old in the newborn intensive care unit. Which term is most accurate when discussing this client?
Newborn A more accurate term for this child would be newborn rather than infant because the newborn or neonatal period of infancy is defined as the period from birth until 28 days of age. Infancy is the period of time up to 1 year old. Child and baby don't refer to the client's age accurately.
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 (3.6 kg) and was 20 in (50.8 cm) in length. Which finding is most consistent with the normal infant growth and development?
The baby weighs 16 lb (7.3 kg) and is 26 in (66.0 cm) in length. The average infant's weight doubles at 6 months and will triple at 1 year of life. The infant's length will increase by 50% by the first year.
The nurse is assessing the sleeping practices of the parents of a 4-month-old girl who wakes repeatedly during the night. Which parent comment might reveal a cause for the night waking?
They put her to bed when she falls asleep. If the parents are keeping the child up until she falls asleep, they are not creating a bedtime routine for her. Infants need a transition to sleep at this age. If the parents are singing to her before she goes to bed, if she has a regular, scheduled bedtime, and if they check on her safety when she wakes at night, then lie her down and leave, they are using good sleep practices.
Which activity is most beneficial in the development of the newborn?
Being sung to by his mother Interaction between the newborn and his parents is the most beneficial activity. Later toys and music may have a good influence but initially the parental interaction is best.
Infant development is best described by which statement?
Development proceeds cephalocaudally. Growth and development both proceed from head to toe, or in a cephalocaudal sequence. The baby needs first to learn to lift the head. Once that developmental milestone has been achieved then progression can occur to rolling over and then learning to sit. Development proceeds in a proximodistal fashion. Skills are learned in a gross motor fashion before devolping fine motor skills. Infants may develop skills at different ages but the process is always sequential. Unless there are other problems to interfere with development, all children will develop in the same manner.
The nurse is assessing the 10-month-old infant. The nurse notes the anterior fontanel has closed. What initial action by the nurse is indicated?
Document the findings as normal. The anterior fontanel most often closes between 12 and 18 months of age. It may normally close as early as 9 months of age. The closure of the fontanel at 10 months of age, while somewhat early, does not signal any health issues for the infant.
The pediatric nurse is careful to monitor and assess the growth and development of all clients. Which characteristic should the nurse prepare to assess in the infants?
Grows and develops skills more rapidly than at any other time in their life. The infant grows and develops skills more rapidly than he or she ever will again. The toddler insists he or she can do things one minute and then becomes dependent the next minute. The preschool age child soaks in information and asks "why" and "how" over and over. The school-age child has a longer attention span and can become absorbed in a craft or activity for several hours.
The nurse is reveiwing 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.
The nurse is assessing the oral cavity of a 6-month-old child. When palpating the location in which the first primary teeth erupt, which location is being assessed?
Lower central gum line The lower central incisors are usually the first to appear, followed by the upper central incisors.
The nurse is teaching healthy eating habits to the parents of a 7-month-old girl. Which recommendation is the most valuable advice?
Serve new foods several times When introducing a new food to an infant, it may take multiple attempts before the child will accept it. Parents must demonstrate patience. Letting the child eat only the foods she prefers, forcing her to eat foods she does not want, or actively urging the child to eat new foods can negatively affect eating patterns.
A mother of a 10-month-old states to the nurse, "I brush my child's teeth every day with flavored kids' toothpaste." Which is the most appropriate response by the nurse?
"Toothpaste is not necessary; it is the scrubbing that is required." Toothpaste for infants is not required. The important health technique is the removing of plaque, and that is accomplished through scrubbing of the teeth.
The nurse is educating the mother of a 6-month-old boy about the symptoms for teething. Which symptom would the nurse identify?
Increased biting and sucking The nurse would advise the mother to watch for increased biting and sucking. Mild fever, vomiting, and diarrhea are signs of infection. The child would more likely seek out hard foods or objects to bite on.
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?
Recommend the parents provide the infant a cold teething ring to chew Chewing on a cold ring can be very soothing for the tender gum lines during teething. Warm foods offer no relief from teething. Numbing agents are not recommended as they increase the risk of choking. Acetaminophen should not be administered routinely. It may be given every 4 to 6 hours as needed.
The mother of a 1-month-old infant voices concern about her baby's respirations. She states they are rapid and irregular. Which information should the nurse provide?
The respirations of a 1-month-old infant are normally irregular and periodically pause. The normal respiratory rate for a 1-month-old infant is 30 to 60 breaths per minute. By 1 year of age the rate will be 20 to 30 breaths per minute. The respiratory patterns of the 1-month-old infant are irregular. There may normally be periodic pauses in the rhythm.
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.
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 more questions to see if there are symptoms of colic." The nurse should seek more information to assess the infant's symptoms. The symptoms suggest colic, which is characteristic of an infant who cries more than 3 hours a day and is fussy and hard to console. The other responses are non-therapeutic and do not seek further information to gather a history.
The mother of a 6-week-old infant reports she doesn't know if her child recognizes her face yet. What response by the nurse is most appropriate?
"Since about 4 weeks of age your child has been able to recognize those who are around him often." At 1 month of age the infant can recognize by sight the people he or she knows best. Telling the child's mother that this will come with time is not correct as this developmental milestone has already occurred. Telling her not to worry minimizes her questions and concerns.
The mother of an infant questions the nurse about her baby's teething. The nurse provides client education. Which statement by the mother indicates understanding of the information provided?
"The first teeth that will likely appear are the lower incisors." 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 first time breastfeeding mother phones the clinic nurse because she is concerned about her 3-month-old's stools. Which statement indicates a possible problem?
"The stools are foamy and smell terrible." Stools from a breastfeeding infant are different than from a formula fed infant. The infant stools more frequently, the contents are yellow seedy There is little or no odor to the stool. Foamy or foul smelling stools may indicate a digestive problem or illness. The health care provider or nurse practitioner should be contacted. All the other statements describe normal stooling.
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, crying and straining during bowel movements by infants and newborns is normal. This is due to the immaturity of the gastrointestinal system. The most important thing to do initially is to determine the appearance of the stool. The grunts and cries are not of concern unless the stool is dry and hard, so asking about the characteristics is the initial response. Simply indicating this is normal without having additional information is not the appropriate response. There is no need for a stool specimen based upon the infomation provided.
The nurse enters her client's room and finds the infant on a pillow with a bottle propped up while the mother is dressing. What statement should the nurse make?
"You should always hold your baby for feedings instead of propping the bottles." The nurse should educate the mother on the risks of propping bottles with infants. Infants are at risk for aspiration of milk and for otitis media. The other choices do not point out the safety risks or educate the mother.
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 rice cereal should be first. The infant should be monitored for food allergies by following the rice cereal with oats, barley, and wheat. Wheat has the highest allergy reaction in infants.
The parent of 1-week-old infant voices concerns about the infant's weight loss since birth. At birth the infant weighed 7 lb (3.2 kg); the infant currently weighs 6 lb 1 oz (2.8 kg). Which response by the nurse is most appropriate?
"Your infant's weight loss is within the expected range." The normal newborn may lose up to 10% of one's birth weight. This infant has lost 8.7%. This degree of weight loss will likely not require hospitalization. Expressing to the parent that the infant may be hospitalized is rash and will most likely not occur.
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 (5900 g) The average newborn weighs 7.5 lb (3400 g). The average newborn looses 10% of birthweight over the first week of life but regains it in about 10 to 14 days. Most infants double their birth weight by 4 months of age and triple their birth weight by the time they are 1 year old. If the newborn weighed 6 lb 8 oz (2,912 g) at birth and doubled that weight at 4 months the infant should weigh 13 lb (6.5 lb × 2 = 13 lb).
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 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 The work of children is play. Play provides a natural way for the infant to learn. In early infancy infants prefer their parents rather than toys. Parents can talk and sing to infants during feeding, bathing, and changing diapers. Infants do not need a daily bath as long as the diaper area is washed with diaper changes. Soap is actually drying to an infant's skin. Washing the hair with soap can help remove excess oil.
A newborn requires skin care that includes bathing. Besides hygiene, what is another reason for bathing the newborn?
Bathing is a time for bonding with the parents. The parents can use bath time for bonding with their newborn. This can be done with talking, cooing, and singing. Bath time should be slow-paced and nonstressful. Newborns prefer interacting with parents over toys and they love to watch people's faces. Bathing can help prevent infection, but it is a secondary response. Using soaps on the skin tends to dry the skin, not moisten it. After bathing, lotion can be applied. It is soothing to the baby and keeps the skin softened.
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). 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 2-month-old infant has inconsolable crying, is gassy, and constantly draws the legs up. It has been determined that the infant has colic. What intervention should the nurse recommend to treat colic?
The infant is bottle fed, so the parent needs to try a different formula to assess for sensitivity. Colic is defined as inconsolable crying that lasts at least 3 hours or longer per day. Colic can begin as early as 2 weeks and usually resolves itself by 3 months. Parents should take a stepwise approach to resolving colic. The first step is to make sure all the infant's needs are met. Then decrease any stimuli, use soothing techniques such as carrying the infant, swaddling, pacifiers, etc. If the infant is formula fed, it may be necessary to see if changing to sensitive formula would help. The breastfeeding mother should not be eating any gas producing foods and should limit the amount of caffeine intake to see if diet plays a role in producing colic.
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 By 9 months, an infant usually speaks a first word: "da-da" or "ba-ba." The other answers refer to earlier milestones in language development. In response to a nodding, smiling face, or a friendly tone of voice, a 3-month-old infant will squeal with pleasure or laugh out loud. By 4 months, infants are very "talkative," cooing, babbling, and gurgling when spoken to. At 6 months, infants learn the art of imitating. They may imitate a parent's cough, for example, or say "Oh!" as a way of attracting attention.
The nurse at a family health clinic is teaching a group of parents about normal infant development. What patterns of communication should the nurse tell parents to expect from an infant at age 1?
Understands "no" and other simple commands At age 1, most babies understand the word "no" and other simple commands. Children at this age also learn one or two other words. Babies squeal, make pleasure sounds, and use multisyllabic babbling at age 6 months. Using speech-like rhythm when talking with an adult usually occurs between ages 9 to 12 months.
A new mother reports that she is exhausted and that the little sleep she gets is determined by her baby. Which suggestion should the nurse prioritize to help the mother establish healthy sleeping patterns in her infant?
Use the crib for sleeping only, not for play activities. A consistent bedtime routine is usually helpful in establishing healthy sleeping patterns and in preventing sleep problems. Using the crib for sleeping only helps the child associate the bed with sleep. Depriving the baby of sleep during the afternoon or evening will make the baby over-tired and less able to establish a healthy sleeping pattern. While letting a baby cry for a while is acceptable, this does not promote consistency in the baby's sleeping pattern.
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 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 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?
"Bottles given at bedtime can cause erosion of the enamel on the teeth." The sugar from formula or sweetened juice coats the infant's teeth for long periods and causes erosion of the enamel on the deciduous teeth. While giving water in a bottle at bedtime is acceptable and a pacifier will satisfy the sucking need, the most appropriate response is to warn of possible enamel erosion. Giving a bottle at bedtime is not a factor that leads to obesity.
During a well-baby visit the mother of a 3-month-old infant tells the nurse that she does not understand why her baby continues to spit out food during feeding of solid foods. What is the best response by the nurse?
"Infants still have a tongue protrusion reflex until 4 to 6 months so they can't help but push out the solid food." Introducing solid food with a spoon prior to 4 to 6 months of age will result in extrusion of the tongue. The parent may think that the infant does not want the food and is spitting it out intentionally, but the extrusion reflex is still present.
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 infant state the child is in by what the mother says and that it is okay to try and feed the infant?
"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.
A mother asks the nurse where the microwave is so that she can warm up breastmilk to feed her baby. What is the best response by the nurse?
"You should warm the milk under warm water instead." A microwave can heat unevenly and cause burns and therefore should never be used to heat breastmilk or formula for an infant. In addition, it can change the immune properties of the breastmilk.
When performing neurological reflexes on the infant, which primitive reflex will be present longest?
Babinski 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.
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. 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 other 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 one's own position which helps, not just placing the infant on the back. Doubling up the formula will not help colic and may cause more problems, because it can cause abdominal pain and increased weight gain.
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 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.
What action shows an example of Erik Erikson's developmental task for the infant?
The infant cries and the caregiver picks the child up. Erikson's psychosocial developmental task for the infant is to develop a sense of trust. The development of trust occurs when the infant has a need and that need is met consistently. Crying with a wet diaper without a change of the diaper leads to an unmet need. Playing peek-a boo and smiling are developmental tasks that indicate a normal healthy, happy baby. These would be attributed to Piaget theory.
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 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.
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 At four months of age, the infant is able to lift the head and look around. The infant can roll from prone to supine. When being pulled up, the head leads. The 4-month-old infant can make simple vowel sounds, laugh aloud, and vocalize in response to voices. A fear of strangers does not occur until the child is older and a 4-month-old infant has not developed emotionally to have "moody" periods and is dependent on parental care.
The student nurse is reviewing the records of a pediatric client. Which statement about the client's progress indicates the need for further instruction?
"Maturation refers to the child's increases in body size." Growth refers to an increase in physical size. Development is the sequential process by which infants and children gain various skills and functions. Heredity influences growth and development by determining the child's potential, while environment contributes to the degree of achievement. Maturation refers to an increase in functionality of various body systems or developmental skills.
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 mother of a newborn reports she does not think her baby likes his formula since he spits up after only taking a small amount. Which response by the nurse is most appropriate?
"Your baby's stomach is small and can only hold about 1/2 to 1 ounce at birth." At the time of birth an infant's stomach can only hold 1/2 to 1 ounce. This will gradually increase. While it is true that the infant does not eat much this does not meet the educational needs of the mother and is not the best response. Burping is a part of normal newborn feeding practices but is not the best response. There is no indication there is a milk intolerance from the information reported.
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.
Which milestone would the nurse expect an infant to accomplish by 8 months of age?
Sitting without support 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 caring for the family with a 2-month-old boy with colic. The mother reports feeling very stressed by the baby's constant crying. Which intervention would provide the most help in the short term?
Urging the baby's mother to take time for herself away from the child Urging the parents to get time away from the child would be most helpful in the short term, particularly if the parents are stressed. Educating the parents about when colic stops would help them see an end to the stress. Observing how the parents respond to the child helps to determine if the parent/ child relationship was altered. Assessing the parents' care and feeding skills may identify other causes for the crying.
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." The nurse should notice this is not the proper place for a car seat. The car seat should be rear facing and in the center of the back seat of the car. The nurse would review car seat safety with the mother and have her install the seat properly. The nurse should provide written materials if available. The other responses are not appropriate and do not ensure that proper installation will occur and that infant safety will be maintained.
The nurse is providing a nutrition workshop for the parents of infants. The nurse understands that further instruction is required when hearing which comments from the parents? Select all that apply.
-"Food is so expensive. I can't afford for my child to leave any food on the plate." -"I have tried at least 10 times with every green vegetable and I can't get my son to like them." -"I let my child eat whatever he wants right now so that we don't argue about food. Hopefully he will like healthy foods when he grows up." Encouraging children to eat everything on their plate can lead to overeating and obesity. Children may need to be exposed to new food at least 20 times before determining if they like it or not. Letting a child eat whatever he wants does not lead to good choices as the child matures.
A group of nursing students are preparing a presentation illustrating basic safety measures which can be utilized for infants. Which measures should the students prioritize in their presentation? Select all that apply.
-Crib and playpen bars should be no more than 2 3/8 inches apart. -Car seats should be placed in back seats. -A safe temperature for hot water heaters in households with infants is 120°F (48.9°C). Crib and playpen bars should be no more than 2 3/8 inches apart so the infant can be safe from getting body parts caught between the bars. Car seats are placed in the back seat and manufacturers' instructions are followed regarding forward or backward facing depending on the age and size of the child. Water heaters should be set no higher then 120°F (48.8°C) to prevent potential burns. Bottles should never be propped and pillows are not placed in cribs of infants.
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) The average weight of a newborn is 7.5 lb (3400 g). The infant gains about 30 g each day. By four months of age, the infant has doubled the birthweight. By 1 year of age, the infant has tripled the birthweight and has grown 10 to 12 in (25 to 30 cm). 7.25 lb × 3 = 21.75 lb or 21 lb 12 oz
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 infant measured 20 in (50 cm) at birth. If the infant is following a normal pattern of growth, which range would be an expected height for this child at the age of 12 months?
30 to 32 in (76 to 81 cm) The average newborn is 20 in (50 cm) in length. The infant grows more quickly in length during the first 6 months of life than the last 6 months of their first year. By 12 months the infant's length has increased 50%. That would mean a 20-in (50-cm) infant would have grown approximately 10 in (25 cm) in 1 year, making the normal length be 30 to 32 in (76 to 81 cm).
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. 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.
The nurse is assessing the oral cavity of a 4-month-old infant. Which finding is consistent with a child of this age?
No teeth Normally infants are not born with teeth. Occasionally there are one or more teeth at birth. These are termed natal teeth and are often associated with anomalies. The first primary teeth typically erupt between the ages of 6 and 8 months.
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 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.
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. 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 chronological 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 chronological age of 8 months: 6 months.
The student nurse is reviewing the chart of a newborn. The document indicates the newborn is in the quiet alert state. Which is the best description of this sleep phase?
The newborn's eyes are open and no body movements are noted. The normal newborn moves through 6 stages of consciousness. The quite alert state is when the infant's eyes are open but the body is calm. Open eyes accompanied by body movements is characteristic of the active alert state.
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. The Moro reflex is seen in the infant as a sudden extension of the head with the arms abducted and moving upward. In this position the hands for the letter "C". This reflex is present at birth and disappears around 4 months of age. This reflex is known as the startle reflex because the baby looks startled when this is seen. It is a normal reflex and there is no need for medical intervention.
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 her crib at the last place she saw it. Looking for the toy where it was last seen indicates object permanence. The infant knows the object still exists even though she cannot see it. All the rest of the infant's behaviors show use of her senses and motor activity but do not illustrate object permanence.
The nurse is reviewing the medical record of an infant who is being seen for the 12-month well-child visit. Which findings are normal for this infant? Select all that apply.
-Heart rate 101 beats per minute -Blood pressure 100/50 -Respiratory rate 28/minute -Temperature 99 degrees Fahrenheit The respiratory rate slows from an average of 30 to 60 breaths in the newborn to about 20 to 30 in the 12-month-old. As the cardiovascular system matures, the average pulse rate decreases from 120 to 140 in the newborn to about 100 in the 1-year-old. Blood pressure steadily increases over the first 12 months of life, from an average of 60/40 in the newborn to 100/50 in the 12-month-old.
The nurse is completing a developmental assessment on a 6-month-old infant. Which findings indicate the need for additional follow-up? Select all that apply.
-The infant does not pay attention to noises behind him. -The infant has frequent episodes of crossed eyes. -The infant seems disinterested in the surrounding environment. Warning signs that may indicate problems with sensory development include the following: young infant does not respond to loud noises; child does not focus on a near object; infant does not start to make sounds or babble by 4 months of age; infant does not turn to locate sound at age 4 months; infant crosses eyes most of the time at age 6 months. Language development at this stage of development does not include stringing together 2-word sentences.
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. Birth weight should triple by 12 months. The child should weigh near 24 pounds 12 ounces (11.25 kg). The child is underweight for age.
The nurse goes in to check on a new mother to see how breast-feeding 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 are doing a wonderful job attempting to wake the baby." The nurse should be emotionally supportive to the new mom. The mom's techniques are commonly used in breastfed infants who are sleeping. The encouragement from the nurse will support the mom through this learning period. The other responses do not emotionally support the mom or contribute to a positive learning environment.
The postpartum nurse observes new mothers as they put their newborns in the bassinet to sleep. Which actions by the new mothers require further instruction from the nurse? Select all that apply.
-A mother places her newborn on its side after falling asleep -A mother states all of her children like sleeping on their abdomen and this newborn likes it too -A mother places the baby comforter her grandmother made over the newborn's body -A mother states her baby looks too warm, so she is moving the bassinet in front of the air conditioner to cool him off Newborns and infants should be on their backs when sleeping in order to help prevent sudden infant death syndrome (SIDS). a firm mattress without pillows or comforters should also be used. The baby's bed should be placed away from air conditioner vents, open windows, and open heaters.
An infant is breastfed. When assessing the stools, which findings would be typical?
Less constipation than bottle-fed infants The first stool of the infant is meconium. It is the result of digestion of amniotic fluid and it is black-green color and sticky. Following that, in 1 to 2 days the infant's stools change to a yellowish-tan color. The stools of breastfed infants tend to be yellow-tan. They are looser in texture and appear "seedy." The stool of a bottle-fed baby has the consistency of peanut butter. The stools of breastfed babies generally have no odor since all milk is digested. Some babies will have a bowel movement with every feeding but it is small. Bottle-fed babies have less stools each day but they are larger and more likely to have an associated odor.
The nurse is assessing the newborn. Which would the nurse assess to be an abnormal finding?
Natal teeth noted in the mouth that are loose The presence of 1 or 2 teeth at birth (natal teeth) is a finding that may be benign or may point to other congenital abnormalities. The neck should be short, thick and mobile. The gluteal folds should be symmetrical. It is normal for the newborn to startle to loud sounds.
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 client should restrain the baby in a car seat when driving. Infants are especially vulnerable to injuries resulting from falls from changing tables or being unrestrained in automobiles. Locking the cabinets and giving warm bottles of formula to the baby are secondary teachings.
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?
"You may be right since infants can sense their mother's smell as early as 7 days old." The sense of smell develops rapidly: the 7-day-old infant can differentiate the smell of his or her mother's breast milk from that of another woman and will preferentially turn toward the mother's smell.
The nurse is teaching the parents of a 6-month-old boy about proper child dental care. Which action will the nurse indicate as the most likely to cause dental caries?
Putting the baby to bed with a bottle of milk or juice The nurse will warn against putting the infant to bed with a bottle of milk or juice because this allows the sugar content of these fluids to pool around the infant's teeth at night. Not cleaning the infant's gums when the infant is done eating will have minimal impact on the development of dental caries, as will using a cloth instead of a brush for cleaning teeth when they erupt. Failure to clean the teeth with fluoridated toothpaste is not a problem if the water supply is fluoridated. Fluoridated toothpaste is recommended for use once the infant is able to not swallow during brushing.
