Ch. 25
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 mostappropriate?
"What does his stool look like?" (p.929)
The parents of a 4-day-old infant report concern about his weight loss. What is the best response by the nurse?
"With appropriate nutrition weight gain will commence with a return to the birth weight within 2 weeks." (p.938-939)
The nurse is providing anticipatory guidance to the parent of a 2-month-old infant in relation to growth and development. Which statement from the parent demonstrates proper understanding?
"I can expect my infant to be able to raise the head up when on the stomach within the next month." (p.924-937)
The nurse is interacting with several parents of infants. Which parent statement would alert the nurse to refer the infant for further evaluation by the health care provider?
"My 9-month-old infant is beginning to track objects when we show her favorite objects." (p.933)
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 a chatterbox and smiles just like her brother." (p.937)
A teen mom asks the discharge nurse if it is okay to sleep in bed with her baby. She says her mom always did it with her siblings and it seemed okay. How should the nurse respond?
"The baby can sleep in your room in an infant crib, but not in an adult bed." (p.949)
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." (p.933)
A mother asks the nurse where the microwave is so that she can warm up breast milk to feed her baby. What is the best response by the nurse?
"You should warm the milk under warm water instead." (p.947)
The nurse is assessing the neurological status of a 10-month-old infant. Which finding(s) does the nurse determine to be abnormal when performing this assessment?
- The infant demonstrates reflexive sucking when nipple or finger is placed in infant's mouth. - The infant turns to the right side, searching with mouth, when the right side of the cheek is stroked. - The infant reflexively grasps when the nurse touches the palm. - With sudden extension of the infant's head, the arms abduct and move upward and the hands form a "C". (p.926)
The nurse is completing a developmental assessment on a 6-month-old infant. Which findings indicate the need for additional follow-up?
- 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. (p.934)
The infant weighs 6 lb 8 oz (2,950 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 12 months?
19 lb 8 oz (8825 g) (p.924)
The infant weighs 7 lb 4 oz (3,300 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) (p.924)
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) (p.924)
When performing neurological reflexes on the infant, which primitive reflex will be present longest?
Babinski (p.925)
The nurse is assessing the 10-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. (p.925)
An infant is breastfed. When assessing the stools, which findings would be typical?
Less constipation than bottle-fed infants (p.929)
The nurse is providing helpful feeding tips to the mother of a 2-week-old boy. Which recommendations will best help the child feed effectively?
Maintain a feed-on-demand approach. (p.944)
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. (p.932)
The nurse in a pediatric clinic is reviewing the chart of an infant who is 12 months old. The infant weighed 8 lb 3 oz (3720 g) at birth. What does the nurse anticipate the infant's weight to be in kilograms if the infant meets normal growth expectations? Record your answer using one decimal place.
Most infants triple their birth weight by 12 months of age. If the infant weighed 8 lb 3 oz (3720 g) at birth, triple that weight at 12 months would be 11160 g. 100 g = 1 kg; 11160 g = 11.16 kg, rounded to 11.2 kg. (p.924)
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 (p.929)
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 (p.951)
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?
Respond promptly when the infant cries. (p.931)
A nurse is educating a client being discharged with her newborn baby. What is the highest priority item that must be included in the teaching plan?
Restrain the baby in a car seat. (p.949)
A new mother, when asked by a nurse, explains that her 4-month-old infant has been nursing regularly every 3 to 4 hours and seems satisfied. However, the mother recently introduced solid food in the form of unbuttered popcorn to the baby as a supplement, to "get her used to eating solid food." She felt that the popcorn would be safe because it is soft on the baby's gums. What should be the primary nursing diagnosis in this situation?
Risk for aspiration related to feeding the infant an inappropriate food (p.948)
Which milestone would the nurse expect an infant to accomplish by 8 months of age?
Sitting without support (p.932)
The nurse in a community clinic is assessing a 2-month-old infant. The parent asks if the infant is developing normally. The nurse refers to which finding as suggestive of normal development in infants from birth to 2 months of age?
The infant raises head and chest while on stomach. (p.924)
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. (p.924)
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 (p.941)
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. (p.941-942)
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 (p.949)
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 (p.924)
The nurse is teaching the parents of a 6-month-old infant about proper dental care. Which action will the nurse indicate as most likely to cause dental caries in this infant?
putting the infant to bed with a bottle of milk or juice (p.949)
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. (p.931)
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. (p.925)
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 less than expected for age. (p.924)
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 16 lb (7300 g) and length of 26 in (66.0 cm) (p.924)
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 0.5 oz and 1 oz. (p.929)
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. (p.925)
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 best response by the nurse?
"Delays are normal when a child is premature." (p.924)
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?" (p.936)
The nurse is documenting the relationship between a postpartum mother and her infant. Which observation would demonstrate attachment?
"The mom is talking to the infant while breastfeeding the infant." (p.946)
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 reflecting height/weight would the nurse expect to document for this visit?
24 pounds (10.8 kg) and 30 inches (75 cm) (p.924)
A 3-month-old infant has a Moro reflex. Which statement is most true of this reflex?
Infant may retain the Moro reflex at 3 month old; it fades between 2 and 4 months. (p.926)
What action shows an example of Erik Erikson's developmental task for the infant?
The infant cries and the caregiver picks the child up. (p.931)
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 (p.951)
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. (p.931)
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 gumline (p.929)
The nurse is making a home visit and observes the 7-month-old pulling the family dog's hair and ears. Which parenting skill does the nurse determine is most effective?
The parent tells the child "no" with a stern voice and pulls the child's hand away from the dog (p.950)
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." (p.951)
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 0.5 to 1 oz at birth." (p.929)
