chapter 17
Where do most accidents occur?a. In the homeb. In the carc. At day cared. On the playground
ANS: A Accidents occur in many situations: in the home, outside, on the playground, and in automobiles. However, most accidents occur in the home.
A 2-month-old infant is in for a well-baby visit. Which of the following immunizations should the nurse administer to the infant?a. DTaP-1b. MMRc. Varicellad. Influenza
ANS: A The Centers for Disease Control and Prevention (2007) recommends the following vaccines at 2 months of age: DTaP-1, Hib-1, PCV, Polio, RV.
A nurse would like to be involved in promoting change in health care policies. Which of the following actions would be most appropriate for the nurse to accomplish this goal?a. Be an active member of a national nursing organization.b. Vote for political leaders in favor of health care reform.c. Enroll in a health policy class.d. Learn about community resources.
ANS: A The best way for a nurse to promote change in health care policies is to be an active member of a national nursing organization. As an active member, she can join other professionals in lobbying for change.
An infant is lying in a crib watching and listening to a colorful mobile. What is the purpose of having a mobile?a. Provides stimulation necessary for continued growth and development for the infantb. Provides too much stimulation for the infant, making it difficult for the infant to focusc. Serves as inadequate stimulation for the infant because it is an inanimate objectd. Serves as a distractor for the infant, making it easier to fall asleep
ANS: A The mobile is providing the stimulation necessary for continued growth and development because both auditory and visual stimuli are necessary to promote growth and development. Additionally, soft sounds and voices are soothing to infants.
A mother asks a nurse what the best toy would be for her 2-month-old. Based on the growth and development of the infant, which of the following recommendations should be made by the nurse?a. Colorful mobile with musicb. Rattlec. Stuffed teddy beard. Play telephone
ANS: A The most appropriate toy based on the child's age and developmental level would be a colorful mobile with music. At this age, the infant can listen to sounds and follow objects. The mobile provides visual and auditory stimulation to continue to promote growth and development.
The mother of a 3-month-old is concerned because her infant usually falls asleep halfway through his bottle. Because of this, the mother is afraid he will not grow well and get sick. Which of the following would be the most therapeutic response by the nurse?a. Ask the mother about the infant's feeding schedule.b. Assure the mother that he is growing fine.c. Tell the mother that half a bottle is probably enough for him.d. Tell the mother she should start to add solids to his diet.
ANS: A The most therapeutic response would be to ask the mother about the infant's feeding schedule. The mother's concern needs to be explored further so that the nurse can understand if the child is receiving adequate nutrition. This response will open the lines of communication and allow the mother to discuss her fears as well as the feeding schedule. Parents look to nurses for anticipatory guidance. The nurse should listen before giving advice. Knowing the feeding schedule will help to determine the best intervention.
A delivery room nurse senses disappointment when a mother is told she just delivered a baby girl. Which of the following would be the most therapeutic response by the nurse?a. "Yes, you just delivered a healthy, beautiful baby girl."b. "This is your first baby. You can always try again for a boy."c. "Don't worry, many parents often feel the same way you do."d. "You are tired. I think you should get some rest."
ANS: A The nurse should respond by saying, "Yes, you just delivered a healthy, beautiful baby girl." This response provides information that will help increase the mother's acceptance of having a girl rather than a boy. Acceptance and bonding are important in preventing child abuse. The fact that the mother appeared disappointed should be acknowledged with a positive comment.
A 15-month-old infant has been brought into the office by his Spanish-speaking mother for symptoms of an upper respiratory infection. Which of the following should be the initial action taken by the nurse?a. Ask the mother if she would like an interpreter.b. Ask the mother what home remedies have been used.c. Ask the mother how long the child has had these symptoms.d. Ask the mother about any allergies the child may have.
ANS: A The nurse should start by asking the mother if she would like an interpreter. Once the need for an interpreter has been established, the nurse can continue with the other questions.
A nurse is developing an educational program about SIDS for a new mothers' support group in the community. Which of the following information would be included in this presentation?a. Parents are encouraged to place their infants in the supine sleeping position.b. SIDS is the leading cause of death among infants age 6 months to 1 year old.c. SIDS is associated with infants who have had difficulty sleeping at night.d. Parents are encouraged to limit the amount of "tummy time" of their infant.
ANS: A Through the Back to Sleep program developed by the AAP, there has been a lower number of infant deaths from SIDS. This has encouraged the supine sleeping position. One of the consequences of the supine sleeping position is plagiocephaly. The primary intervention to decrease the risk of plagiocephaly is "tummy time." Parents should be instructed to allow supervised tummy time while the infant is awake and cautioned about the amount of time their infant spends in a car seat. SIDS is the leading cause of death among infants 28 to 365 days of age. By definition, the cause of SIDS is not known.
A nurse is using the Denver Developmental Screening Test (DDST) II to assess a 10-month-old infant. Which of the following purposes does this screening serve? (select all that apply)a. Screens apparently healthy infants for developmental problemsb. Allows the infant's growth patterns to be compared with other infantsc. Validates intuitive concerns about an infant's development using an objective testd. Monitors high-risk children for developmental problems
ANS: A, C, D The Denver Developmental Screening Test (DDST) is one of several standardized tools that screens for developmental problems in children from birth to 6 years of age. The purposes identified for administering the Denver II: screening apparently healthy infants for developmental problems; validating intuitive concerns about an infant's development with an objective test, and monitoring high-risk children for developmental problems.
A nurse is completing a home visit of a new mother who is breast-feeding her infant. Which of the following instructions should the nurse provide during this visit?a. Consume 500 kcal/day above pre-pregnancy energy intake to avoid excessive weight loss.b. Drink 1 quart of fluids daily to produce sufficient quantity of breast milk.c. Use formula to provide the infant supplementation between feedings.d. Use a pacifier to help the infant to fall asleep so he does not fall asleep when breast-feeding.
ANS: B Community nurses who are caring for breast-feeding mothers should stress the following tips to increase the duration of this activity: drink 1 quart of fluids daily to produce sufficient quantity of breast milk; consume 300 to 400 kcal/day above pre-pregnancy energy intake to avoid excessive weight loss; learn the appropriate interventions for engorged breasts, sore nipples, plugged ducts, infection, and leaking; learn about the use of breast pumps and milk storage; join breast-feeding support groups for continued help within the community; learn about the effects of drugs, environmental pollutants, alcohol, and nicotine on breast milk. The use of formula and pacifiers should be discouraged with new infants who are breast-feeding.
A nurse is assessing a 4-month-old infant during a well-child visit. Which of the following findings will require the nurse to collect additional information?a. The infant's shirt is wet from drooling.b. The infant has gained one pound since her 2-month well-child visit.c. The infant holds his or her head steady when in a sitting position.d. The infant grasps objects with two hands.
ANS: B One of the passive manifestations of abuse includes poor nutrition, failure to thrive, and severe malnutrition. Weight gain of 1 pound in 2 months indicates a problem with the infant's growth and requires further data collection by the nurse. The other assessment findings are normal growth and development for a 4-month-old infant.
A mother asks the nurse when she should start feeding her infant solid foods. Which of the following is the most appropriate response by the nurse?a. "It is recommended that solid foods are introduced no earlier than 3 months of age."b. "It is recommended that solid foods are introduced no earlier than 6 months of age."c. "You should wait until your child is 9 months old to start solid foods."d. "You should wait until your child is 1 year old to start solid foods."
ANS: B The AAP (2011) recommends that waiting until the child is 6 months of age to introduce solid food decreases the tendency to develop food allergies and reduces the risk of childhood obesity.
A new father is installing a car seat for an infant in the car. Which of the following information should be given to the father by the nurse?a. The infant should be in a rear-facing car seat in the front seat.b. The infant should be in a rear-facing car seat in the back seat.c. The infant should be in a front-facing car seat in the front seat.d. The infant should be in a front-facing car seat in the back seat.
ANS: B The AAP recommends rear-facing car safety seats for most infants up to 2 years of age. The back seat is recommended because of the danger posed by air bags.
A nurse is encouraging parents to immunize their infants. Which of the following strategies would be the best way for the nurse to facilitate this?a. Send a reminder for immunizations to the parents.b. Talk to the parents about immunizations during office visits.c. Track clients who have not been immunized.d. Memorize the CDC immunization schedule.
ANS: B The best way for a nurse to encourage immunization is to talk to parents about immunizations during office visits. Immunizations are important in the prevention of disease. Actively broadening one's knowledge base regarding immunizations and developing a close relationship with the parents that promotes open communication are important factors for motivating parents.
An infant is going through the toys in his toy box. He looks at each one before dropping it to the floor and picking the next toy out of the box. Using a growth and development perspective, which of the following conclusions can the nurse draw by assessing this behavior?a. The infant is testing his limits.b. The infant is exploring his environment.c. The infant is expressing his emotions.d. The infant is developing fine motor skills.
ANS: B The infant is exploring his environment. By looking at each toy, he is developing the task of learning to understand and control his world through exploration.
The nurse performs a home visit for a new mother and infant. The nurse observes that the infant lacks a regular feeding schedule, has diapers that are not changed promptly, and cries for long periods of time before being consoled. Which of the following problems is the infant most at risk for encountering in the future?a. Developing enuresis as a toddlerb. Having difficulty forming relationshipsc. Becoming a picky eaterd. Taking longer to toilet train
ANS: B The infant may have difficulty forming relationships in the future because trust influences future relationships. By attending to the infant's needs, parents are helping the infant develop trust in them. Not having his needs attended to hinders that developmental task.
During a home visit to the home of a 3-month-old infant, which environmental finding requires immediate anticipatory guidance?a. A pool in the backyard without a gateb. The lack of smoke detectorsc. The lack of childproof latches on drawers and cupboardsd. Two azalea plants in the living room
ANS: B The lack of a smoke detector places the infant at immediate risk if a fire were to occur. The majority of fire deaths occur in the home, and most people die from smoke inhalation, not burns. At 3 months of age, the infant is not yet able to crawl; thus, the other three findings, although risks, are not immediate.
A 9-month-old has mastered the pincer grasp. Which of the following tasks would the nurse anticipate that the infant can do by himself?a. Play with a rattle.b. Eat cheerios off a hard surface.c. Hold a spoon to feed himself.d. Drink from a cup.
ANS: B The pincer grasp is a fine motor skill that is necessary for picking items up off a surface. By this age, hand-mouth coordination has usually been met and therefore feeding the self with finger foods becomes possible.
A nurse is completing an initial genetic counseling interview with a couple. Which of the following data would be collected during the interview? (select all that apply)a. Paternal ageb. Maternal agec. Family historyd. Religious affiliation
ANS: B, C An important aspect of genetic counseling is identifying families at increased risk and referring them as necessary. Aspects that would be reviewed in the initial interview include: maternal age, ethnic background, family history, reproductive history, and maternal disease.
A new mother has decided to breast-feed her infant after having bottle-fed her other two children. Which of the following information about having a breast-fed infant should the nurse discuss with the mother?a. Breast-fed infants have darker bowel movements than bottle-fed babies.b. Breast-fed infants have smellier bowel movements than bottle-fed babies.c. Breast-fed infants have more frequent bowel movements than bottle-fed babies.d. Breast-fed infants have harder bowel movements than bottle-fed babies.
ANS: C A breast-fed infant's stools have an orange-yellow color and a soft, even consistency, with a slightly sour but clean smell, dissimilar to stools passed later in life. A bottle-fed infant's stools are harder, smellier, and resemble those of an infant eating solid food. The breast-fed infant has many daily stools during the first and second months of life. The bottle-fed infant has two to four stools per day during the first month.
Which of the following infants is most at risk to experience child abuse?a. Father has experienced paternal engrossmentb. Responds to parental touchc. Parents have low-self esteemd. Has been adopted
ANS: C Because the parents' self-esteem is associated closely with their infant's interactions and accomplishments, when parents' self-esteem is low, disappointment, anger, and a disturbance in the relationship with their infant can occur. When a disturbed parent-infant relationship continues, the infant is at risk for abuse and behavior problems. The process of paternal engrossment has been used to describe the behavior patterns of fathers when they interact with their infants.
A nurse is assessing the language development of a 6-month-old infant. Which of the following findings would the nurse anticipate?a. The infant forms two-syllable sounds.b. The infant coos and makes vowel sounds.c. The infant babbles.d. The infant says "ma-ma" and "bye-bye."
ANS: C By 6 months, babbling sounds are heard, and by 9 to 10 months, the infant forms two-syllable sounds. By 12 months, words such as "ma-ma" and "bye-bye" are emerging. Cooing and vowel sounds are heard at approximately 2 to 3 months.
A nurse is working with a family of an infant to improve their health-perception and health management pattern. Which of the following interventions would be most appropriate for the nurse to implement?a. Assess the home for safety hazards.b. Teach parents appropriate coping mechanisms.c. Demonstrate effective parenting skills.d. Encourage appropriate stimulation of the infant.
ANS: C Health is largely a subjective judgment. With this understanding, the nurse uses every opportunity to convey confidence in the parents' health perception-health management pattern and their ability to act to enhance the infant's health. When parents learn and adopt behaviors to improve their own health, they are more likely to ensure that the health needs of their infant are met. Parental modeling increases the changes that good health practices will be retained throughout the child's life.
A new young mother asks the nurse what she should do to play with her 3-month-old infant. Which of the following suggestions should the nurse provide?a. Take the infant for a walk outside.b. Place several toys around the infant when lying on the floor.c. Rock the infant in a rocking chair.d. Search the Internet for toys highly recommended for infants.
ANS: C Parental stimulation of the infant is an important developmental technique. The infant needs stimulation to learn about the world. This activity does not require expensive objects, but rather involves experiences in sight, sound, and touch that are free and can be provided by any parent. One example of a stimulating experience for infants is being rocked in a rocking chair. Infant who are 3 months old will hold toys, but not actively reach for them so surrounding the infant with toys would not be suggested.
By what age is an infant's retina fully developed?a. Birthb. 2 monthsc. 4 monthsd. 6 months
ANS: C Rod cells in the retina of the eyes, which are responsible for light perception, are functional at birth; however, the retina (the organ of visual perception) is not fully developed until approximately 4 months of age.
The mother of a 4-month-old infant is concerned about the possibility of SIDS because her neighbor's daughter passed away last year as a result of SIDS. The mother reports she is so nervous that she has taken up smoking again. The mother informs you that the 4-month-old sleeps supine and takes a pacifier to help her fall asleep. Which of the following statements would be the best response from the nurse?a. "You should place the infant in the bed with you until 6 months of age."b. "You should never give the infant a pacifier while she is sleeping."c. "You should try to stop smoking."d. "You should place the infant on her stomach."
ANS: C The 2011 report from the American Academy of Pediatrics Task Force on SIDS recommended the following: healthy infants should be placed to sleep in the supine position; infants should be placed on a firm sleep surface keeping soft objects, loose bedding, or any objects that could increase the risk of entrapment, suffocation, or strangulation out of the crib; avoid the infant getting too hot by dressing him/her in too many clothes for the environment; keep the infant away from smokers and places where people smoke; sleep with the infant in the same room where you sleep, but not the same bed, for 6 months; and offer a pacifier at nap time and bedtime.
A nurse is completing a well-child assessment of a 6-month-old infant. Which of the following guidelines should be used when assessing the infant's height and weight?a. CDC growth chartsb. CDC body mass index (BMI) chartsc. WHO growth standardsd. Denver Developmental Screening height and weight standards
ANS: C The CDC recommends that health care providers use the WHO growth standards to monitor growth for infants and children ages 0 to 2 years of age in the United States and use the CDC growth charts for children age 2 years and older in the United States.
A 5-month-old boy was born at 6 pounds, 7 ounces. He is being seen in the office for a well-child visit. The nurse would expect him to weigh approximately:a. 10 pounds, 14 ouncesb. 11 pounds, 7 ouncesc. 12 pounds, 14 ouncesd. 13 pounds, 7 ounces
ANS: C The child should weigh approximately 12 pounds, 14 ounces, because by 5 months of age, the child should weigh twice the birth weight.
The mother of an 8-month-old asks what the minimum recommended amount of fat intake is for her 10-kg infant. Which of the following would be the minimum recommended fat intake?a. 18 grams a dayb. 28 grams a dayc. 38 grams a dayd. 48 grams a day
ANS: C The minimum recommended fat intake for this 8-month-old, 10-kg infant is 38 grams per day. The minimum recommended fat intake for an infant this age is 3.8 g/kcal. Thus, 3.8 ´ 10 = 38.
A nurse visits a 3-month-old infant of a single mother for a weight check. She finds two older children running around the home, the infant is crying, the mother yelling at the two children and a half-lit cigarette is in an ashtray. The mother tells the nurse the visit needs to be cut short today because she has to pick up her other children from the bus stop. Which of the following would be the most beneficial intervention this nurse can provide during this visit?a. Leave and tell the mother to call her to reschedule the appointment.b. Weigh the infant and contact the Department of Children and Families.c. Weigh the infant and offer community resources to the mother.d. Offer to go pick up the other children at the bus stop.
ANS: C The most beneficial intervention the nurse can provide is to keep the visit short, weigh the infant, and offer the mother the help of community services. Providing anticipatory guidance is important in maintaining health and preventing abuse. Abusing parents are often socially isolated and have few people to whom to turn. Women are more frequent abusers than men. Furthermore, economic conditions play a role in the care of children.
The mother of a 16-month-old infant asks a nurse her opinion about holiday decorating. Which of the following recommendations should the nurse provide to the mother?a. Avoid hanging a wreath with holly and berries on the front door.b. Avoid hanging decorative pictures of a bearded Santa Claus on the window.c. Avoid placing poinsettia plants around the home.d. Avoid hanging stockings on the fireplace mantle.
ANS: C The mother should avoid placing poinsettia plants around the home because, if swallowed, they could be fatal. By 16 months the infant can walk, and infants are more susceptible than adults to the effects of poisonous plants. Plants should be kept out of reach of infants. Berries on the wreath can also be fatal, but at 16 months, the child would not be able to reach the wreath.
During a home visit, the nurse finds a 9-month-old in a playpen with a couple of toys. Which of the following instructions would be most appropriate for the nurse to provide to the parent to encourage growth and development of the child?a. Encourage the addition of a few more toys to the playpen.b. Suggest keeping the infant in the playpen as much as possible to promote safe play.c. Encourage providing the infant with supervised time outside of the playpen.d. Suggest removing all toys from the playpen.
ANS: CThe nurse should encourage the mother to provide the infant with sufficient supervised time outside of the playpen to allow the child to crawl and explore. These activities help promote growth and development. Additionally, by 9 months of age, most infants are crawling.
A nurse makes a home visit to a 15-month-old following a hospitalization for a fall. Which finding would be concerning to the nurse?a. Radiator heating system in the homeb. The child drinking from a cupc. The child experiencing a temper tantrumd. A decorative bowl filled with colorful marbles on the coffee table
ANS: D A decorative bowl filled with colorful marbles on the coffee table is concerning because by 15 months of age the infant is mobile and can eat finger foods. By 7 months of age, the infant fixates on small objects; therefore a safe environment must be created for the infant. Small objects are the most common causes of foreign body aspiration. A bowl of colorful marbles poses a risk for foreign body obstruction.
A nurse assesses that the task of development of affection for and from others has been met or is in the process of being met by an infant. Which of the following observations has the nurse made?a. The infant smiles at mirror images.b. The infant makes cooing noises.c. The infant begins to smile socially.d. The infant likes to be picked up.
ANS: D An infant who likes to be picked up is displaying affection for others. This task is usually accomplished by 6 months of age.
Which of the following is the most common poison ingested by infants?a. Houseplantsb. Leadc. Cleaning agentsd. Aspirin
ANS: D The most common ingested poison is aspirin, followed by houseplants and cleaning agents.