CHAP 29 (situational)

The nurse is meeting with a group of new mothers of infants and is leading the discussion related to weaning. Which suggestion should the nurse prioritize to this group of mothers concerning weaning their infant?

"It is important to let the infant set the pace for weaning, no matter what age they are."

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."

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."

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

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)

Which client will the nurse assess first after receiving 0700 shift report?

A 12-month-old infant with a blood pressure of 60/40 mm Hg

The nurse is assessing a 6-month-old infant in the clinic. Which characteristic represents normal language development for this age?

Babbling

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.

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 little for age.

A first-time mother calls the pediatrician's office to ask the nurse about her baby's tooth eruption. The baby is 8 months old and still does not have any teeth. What information can the nurse share with this mother that would correctly respond to her anxiety about her baby's dentition?

Tooth eruption is often genetically based, with some families having babies with early tooth eruption, while others have late tooth eruption.

A 6-month-old arrives for a well-baby visit with a case of diaper rash that the parent believes is normal for infants. The parent reports changing the baby's diaper when he wakes up and before naps or bedtime. Which frequency should the nurse point out will better help heal and prevent future incidences of diaper rash?

every 2 to 4 hours

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.

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?"

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 nurse is conducting an educational session at a local community health fair illustrating the various reflexes which are normal in a newborn and how they change as the infant grows and matures. The nurse determines more education is necessary after a member of the audience points out which finding as an expected occurrence?

an extrusion reflux at 9 months of age

When a cup is introduced to infants, the introduction of fruit juice may follow. What type of juice would be appropriate for an infant?

apple juice

The nurse is preparing to teach a class to a group of young parents with infants the basics of introducing solid foods into the diet. Which factor about the food should the nurse point out the infants respond to best when introducing solid foods into the diet?

bland

The nurse is watching a group of infants playing in an infant room at day care. When analyzing the developmental characteristics exhibited, which infant would the nurse identify as being approximately 3 months of age?

infant laying prone with a colorful toy in front

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."

The nurse takes a call from a concerned mother whose infant received routine immunizations the day before and now has a temperature of 101oF (38.3oC), is fussy, and pulling at the injection site. The mother wants to know what she should do. Which is the best response from the nurse to this mother?

"This is a common reaction. Give your child acetaminophen, cuddle him, and apply a cool compress to the injection site."

A new mother expresses concern to the nurse that her baby is crying and grunting when passing stool. What is the nurse's best response to this observation?

"This is normal behavior for infants unless the stool passed is hard and dry."

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."

A nurse on a home visit is providing safety tips to a family of a 1-week-old infant. Which of the following statements by the parents indicates the need for further teaching?

"We will position our infant on his side for sleeping."

The nurse is conducting a class for new parents of infants. The nurse determines the session is successful when the parents correctly choose which instruction concerning bathing their infant?

"When I bathe my baby, I shampoo his hair each time as well."

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

Which developmental milestone would the nurse expect an 11-month-old infant to have achieved?

Sitting independently

A new mother tells the nurse that she a bought car seat for her infant at a garage sale when she was pregnant but that a friend recently told her that she should buy a new one. Which instruction would the nurse give initially?

Check the expiration date on the car seat.

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

At the 6-month-old well-child visit, the parent is concerned that the child is unsteady and often falls over when sitting. What will the nurse advise the parent about this?

The child's stability will progress to independent sitting over the upcoming months.

What action shows an example of Erik Erikson's developmental task for the infant?

The infant cries and the caregiver picks the child up.