M: Ch 23
22. The nurse is teaching new parents strategies to help with newborn colic. Which should the nurse suggest? (Select all that apply.) a. Increase the number of feedings. b. Feed the infant in an upright position. c. Burp the infant frequently during feedings. d. Allow the infant to cry for a period of time. e. Increase carrying time by use of a front carrier pack.
ANS: B, C, E Feeding the infant in an upright position and burping frequently may help relieve discomfort from swallowed air, which can cause colic. Increasing the time spent carrying the infant often produces some improvement for colic. Feeding techniques such as overfeeding may contribute to colic, so the number of feedings should not be increased. Allowing the infant to cry excessively will cause the infant to swallow more air and will exacerbate the colic. PTS: 1 DIF: Cognitive Level: Application REF: 467 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance
19. The nurse is calling a new mother to schedule a routine home visit planned for 48 to 72 hours after discharge. What is the nurse's priority question to help determine the best time for the visit? a. "When will the baby's father be home?" b. "Do you plan on having any visitors in the day or two?" c. "At approximately what time do you think you will be nursing your baby?" d. "When will your home be presentable enough for me to come and visit?"
ANS: C A feeding session should be observed, especially if the mother is breastfeeding. Establishment of milk supply, adequacy of the breast milk, and general support are important topics to discuss for the mother who is breastfeeding for the first time. During the home visit, the nurse performs a physical examination of the mother and infant. Family adaptation to the addition of a new member and the adequacy of the mother's support system is also assessed. Cleanliness of the home environment is only a concern when the baby's health is at risk. PTS: 1 DIF: Cognitive Level: Analysis REF: 463 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance
12. Which statement by a parent indicates a need for the nurse to intervene with teaching? a. "I put my newborn baby on her back when she goes to sleep. I understand this is the best position." b. "Jennifer's eyes sometimes cross, but I know that this is normal in 1-month-old babies." c. "My 5-month-old infant has been drooling, biting, and running a fever for the past few days. I think he's teething." d. "My neighbor has been giving her baby solids since he was 8 weeks old. I think I'll wait until my baby is about 5 months old."
ANS: C Although drooling and biting are signs of teething, a fever should always be considered a sign of illness. A back position is the appropriate position for an infant to sleep. Eye crossing at this age is a normal deviation. Infants should not be started on solids until they are 5 months old. PTS: 1 DIF: Cognitive Level: Analysis REF: 473 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Safe and Effective Care Environment
16. Which should be included in the home care of a high-risk infant? a. Feeding the infant on a strict schedule b. Keeping the infant in the supine or prone position c. Providing continued respiratory support and oxygen d. Cleaning the umbilical cord several times daily with alcohol
ANS: C High-risk infants may continue to need assistance with respiratory function after discharge. The infant does not need to be kept on a strict schedule so as not to disrupt the sleeping patterns of the infant. A high-risk infant should be placed on the side or back as appropriate positions. Cleaning the cord several times a day with alcohol prep is not required. PTS: 1 DIF: Cognitive Level: Understanding REF: 464 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance
1. A client is being prepared for discharge with her newborn. She tells you about the antique crib she inherited from her grandmother and how excited she is about using it for her newborn. Which information should be cause for concern? a. The crib slats are inches apart. b. The crib has been stripped and repainted with a lead-free paint. c. The mattress fits snugly in the crib with ½-inch space around the sides. d. The side rail hardware has been replaced so that the latches remain fastened.
ANS: A An infant's head may become wedged between slats that are more than 3 inches apart. The crib should be painted with lead-free paint, which is safest and appropriate. The mattress needs to fit snugly to prevent suffocation. Replacing the side rail hardware so that the latches remain fastened is the appropriate action to ensure the safety of the crib. PTS: 1 DIF: Cognitive Level: Analysis REF: 466 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance
2. Which intervention will be most helpful to parents in identifying problems with an infant car seat? a. Questioning the parents about the instructions b. Providing the parents with current laws on infant and child safety c. Asking the parents to demonstrate how to secure the infant in the car seat d. Allowing the parents to ask questions and express feelings about infant restraint
ANS: C If the nurse observes the parents demonstrating the use of the car seat, any problems or misunderstandings can be identified. Questioning the parents is not a helpful way to identify problems with a car seat; a return demonstration is better. Providing information without a return demonstration will not prove that the parents are comfortable with the car seat for the infant. A return demonstration is a better way to ensure that the parents understand car seat safety. PTS: 1 DIF: Cognitive Level: Application REF: 466, 467 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment
8. Infant immunizations should begin at which age? a. Birth b. 2 months c. 3 months d. 4 months
ANS: A The schedule of infant immunizations calls for the initial dose of hepatitis B vaccine at birth. The first set of immunizations is given at birth. PTS: 1 DIF: Cognitive Level: Understanding REF: 472 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance
24. The nurse is teaching new parents how to avoid and treat newborn diaper rash. Which should the nurse include in the teaching session? (Select all that apply.) a. Keep the diaper area clean and dry. b. Do not use talc-based powders in the diaper area. c. Cleanse the diaper area with a scrubbing motion. d. Apply a thick layer of zinc oxide to prevent further outbreaks. e. Remove the diaper and expose the perineum to warm air if a rash develops.
ANS: A, B, E Diaper rash is primarily treated by keeping the diaper area clean and dry. Talc-based powders should not be used because they can cause pneumonia if they get into the infant's lungs. Removing the diapers and exposing the perineum to warm air helps healing. Parents should gently wash the perineum with mild soap and warm water but should avoid excessive washing or scrubbing. Applying a thin layer of zinc oxide or petrolatum may speed healing and help prevent further outbreaks. The nurse should tell parents not to apply the ointment too thickly because it may be difficult to remove. PTS: 1 DIF: Cognitive Level: Application REF: 471 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance
21. During a prenatal education class about infant home care, the nurse is reviewing the simulated setting created by new mothers for putting the baby to bed. Which observation indicates to the nurse that the new mothers understood the nurse's teaching about infant safety? a. The crib is lined with a bumper pad. b. Stuffed animals are placed in the crib. c. The baby mannequin is in the supine position. d. The baby mannequin is covered with a handmade quilt.
ANS: C Infants should be positioned on the back for sleep. The nurse should explain that the prone position has been associated with sudden infant death syndrome (SIDS). No pillows, blankets, or soft stuffed animals should be allowed in the crib because they could cause suffocation. Infants can be placed in a zippered blanket sleeper for warmth. PTS: 1 DIF: Cognitive Level: Application REF: 474 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance MULTIPLE RESPONSE
3. Which statement made by a parent indicates a need for the nurse to teach safety and accident prevention? a. "I always take the phone off the hook when I give my baby a bath so I won't be disturbed." b. "I'm going to buy a backpack for my 2-week-old baby so I can carry her in it whenever she gets fussy." c. "I've been reading about what new things my baby will be learning to do in the next month or two, so I'll know what to expect." d. "I make sure I always raise the side of the crib when I put my baby to sleep, even though newborns don't move around as much as older infants."
ANS: B Backpacks should be used only for infants old enough to support their heads well by themselves. "I always take the phone off the hook when I give my baby a bath so I won't be disturbed," "I'm going to buy a backpack for my 2-week-old baby so I can carry her in it whenever she gets fussy," and "I make sure I always raise the side of the crib when I put my baby to sleep, even though newborns don't move around as much as older infants" are appropriate statements regarding safety for a newborn. PTS: 1 DIF: Cognitive Level: Analysis REF: 468 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Safe and Effective Care Environment
13. A new client asks what she can do to help her infant sleep through the night. Which should the nurse instruct? a. Bring the infant into a well-lit room for the feeding. b. Avoid talking to the infant and keep the room quiet during night feedings. c. Play with the infant after the feeding before putting the infant back into the crib. d. Change the infant's diaper after the feeding to prevent waking the infant later in the night.
ANS: B Decreasing stimulation of the infant during and after the bedtime feeding will assist the infant in establishing a normal sleep pattern. Keeping the baby in a quiet, dimly lit room is a better option for a feeding during the night. The baby should be put right back into the crib after a feeding; it is not the time to play with the infant. The infant's diaper should be changed before the feeding is started or can be skipped so as not to disturb the infant too much. PTS: 1 DIF: Cognitive Level: Application REF: 469 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance
7. Which statement is true about growth and development during the first 6 months? a. The infant will grow 1 cm in length per month. b. The infant will gain about 2 pounds per month. c. The infant will regain weight lost after birth within 1 week. d. The infant will have a 1-inch increase in head circumference per month.
ANS: B Each month the average infant gains 2 pounds. Infants grow about 3.5 cm each month. Birth weight is usually regained in 14 days. An infant's head circumference increases about 2 cm a month. PTS: 1 DIF: Cognitive Level: Understanding REF: 472 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance
23. Parents ask the nurse, "How many wet diapers a day should we expect and how will we know the baby's stools are normal?" Which response should the nurse make if the infant is being formula fed? (Select all that apply.) a. The stools should be watery. b. The stools should be dry and hard. c. The infant should have at least one stool a day. d. The infant should have at least six wet diapers a day.
ANS: C, D Formula-fed infants generally pass at least one stool each day. The infant should have at least six wet diapers by the fourth day of life. Stools that are dry, hard, and marble-like indicate constipation. Watery stools indicate diarrhea. PTS: 1 DIF: Cognitive Level: Application REF: 470 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance
11. As the nurse assists a newly discharged client and her infant to the waiting car, the nurse notes that the infant seat is in the front seat of the car facing the front and secured by the seat belt. The nurse should explain to the parents that the car seat should be placed: a. in an upright position. b. at a 30-degree angle. c. not secured by the seat belt. d. in the back seat facing the rear of the car.
ANS: D A car seat in the back seat facing the rear of the car provides protection by keeping the infant from being hurled forward on impact. The car seat should be in the back seat, facing the rear of the car. PTS: 1 DIF: Cognitive Level: Application REF: 466 OBJ: Nursing Process Step: Planning MSC: Client Needs: Safe and Effective Care Environment
4. Which statement made by a new mother should be a cause of concern to the nurse? a. "I will start my baby on solid foods at 5 months." b. "I usually keep the temperature in my house at 72° F." c. "I plan to position my infant on his back when sleeping." d. "I don't intend to spoil my baby by picking him up every time he cries."
ANS: D Infant crying often indicates an unmet need. Parents should be cautioned about ignoring crying. Infants whose parents intervene appropriately for crying are less likely to cry excessively as they grow older. Solid foods should be started no earlier than 5 months. A house temperature of 72° F is appropriate for a newborn. The appropriate position for a baby is on his or her back. PTS: 1 DIF: Cognitive Level: Analysis REF: 467 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Safe and Effective Care Environment
20. A new mother is preparing for discharge from the birthing center and relays to the nurse her concerns about how she will handle her baby's episodes of crying. What is the nurse's best response? a. "I hear your concern. Is there someone in the household who cannot tolerate hearing a baby cry?" b. "It is okay to just let the baby cry from time to time. You don't want to risk spoiling the baby too soon." c. "Infants only cry when they are hungry or if they have gas. If you don't eat any gas-producing food, your baby will cry less." d. "Crying is the way your baby communicates with you. It is important for you to meet your baby's needs consistently and promptly."
ANS: D Infants cannot signal that they have unmet needs in any other way but crying and are not spoiled when parents meet their needs. In fact, their needs must be met in a consistent, warm, prompt manner for the development of trust to occur. Infants who are consistently held when in distress cry less at 1 year and are less aggressive at 2 years of age. Therefore, parents should be taught the importance of consistently and quickly answering infant cries. The response to the assessment of intolerance of crying is a leading question and nontherapeutic communication. Infants cry for many reasons, including hunger, discomfort, fatigue, overstimulation, and boredom. Parents can often identify the problem based on the type of sound made during crying. Sometimes no specific cause can be determined. There is no mention in the stem of the question that the new mother is breastfeeding. PTS: 1 DIF: Cognitive Level: Application REF: 467 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance
9. Which is a sign of illness in the newborn? a. A yellow scaly lesion on the scalp b. More than two soft stools per day c. Regurgitating a small amount of feeding d. An axillary temperature greater than 100.4° F (38° C)
ANS: D Infants commonly respond to a variety of illnesses with an elevation in temperature. Yellow scaly lesions on the scalp are normal findings and are probably cradle cap. More than two soft stools per day are appropriate for a newborn. Regurgitating a small amount of a feeding is a normal variance. PTS: 1 DIF: Cognitive Level: Understanding REF: 473 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance
6. An infant who eats very rapidly may experience problems with swallowing excessive air. What should the mother be instructed to do? a. Use a nipple with a smaller hole. b. Place the infant on the left side after feeding. c. Provide the infant with water between feedings. d. Begin the feeding before the infant becomes too hungry.
ANS: D Infants eat rapidly when they are very hungry. If fed before becoming excessively hungry, the infant will eat at a slower rate. Using a nipple with a smaller hole will not prevent swallowing excessive air. Infants should be placed on the right side or back, but positioning the infant on the left side after feeding will not prevent excessive swallowing. Water should not be given in between feedings. PTS: 1 DIF: Cognitive Level: Application REF: 471 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance
15. Which infant should be seen immediately by a health care provider? a. A 1-week-old infant with a diaper rash b. A 1-month-old infant with an axillary temperature of 99.8° F (37.7° C) c. A 3-week-old breast-fed infant who has had two loose stools d. A 2-week-old infant with nasal congestion and respirations of 64 breaths/min
ANS: D Normal respiratory function is a high priority in the newborn. Any situation in which respiratory function is impaired should be assessed immediately by a physician. Diaper rashes are a normal variant. A temperature of 99.8° F (37.7° C) is still within normal limits. Breast-fed infants have loose stools, so this is a normal finding. PTS: 1 DIF: Cognitive Level: Application REF: 473 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity
18. Which statement by the parents indicates the need for further education with regard to pacifier use? a. "We will discard the pacifier if it becomes torn." b. "We will replace the pacifier every 1 to 2 months." c. "We will be sure to cleanse the pacifier frequently." d. "We will keep track of the pacifier by tying it to a string around the baby's neck."
ANS: D Pacifiers should never be placed on a string around the infant's neck. The string could become tangled tightly around the neck and cause strangulation. If parents make this statement, they need further instruction. When infants use a pacifier, parents should be instructed to examine it often to see if it is in good condition. Cracked, torn, or sticky nipples or nipples that can be pulled away from the shield should be discarded. Pacifiers should be replaced every 1 or 2 months because they may come apart as they deteriorate and cause aspiration of parts. Pacifiers should be kept clean by frequent washing, and parents should buy several so that one is always clean when needed. PTS: 1 DIF: Cognitive Level: Analysis REF: 471 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Safe and Effective Care Environment
17. Which is the priority rationale for doing a car seat trial for a preterm neonate being discharged soon? a. To assess the car seat's size b. To assess the parents' knowledge about car seat use c. To determine if the neonate cries while in the car seat d. To assess for any neonate apnea or bradycardia while in the car seat
ANS: D Some infants have low oxygen levels, bradycardia, or apnea when in a car seat. Facilities often have parents of infants under 37 weeks' gestation or of low birth weight bring their car seat to the hospital to test the infant's response to being placed in the seat. During testing, the infant's vital signs and oxygen level are monitored. Preterm and small infants may need special adaptations. Blankets or bolsters placed at the head, along the sides, and between the legs may improve the fit, but that is not the priority reason for doing a car seat trial. The parent's knowledge should be assessed, but it is not the priority for a car seat trial. The neonate may cry in the car seat, but that is not the reason for the car seat trial. PTS: 1 DIF: Cognitive Level: Analysis REF: 466 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Safe and Effective Care Environment
14. A new mother asks, "Why should I bring my baby in for a checkup? He isn't sick." Which is the nurse's best response? a. "Please ask your pediatrician to explain this to you." b. "He may have a problem that you haven't identified." c. "These visits are required by law to identify communicable diseases." d. "Well-baby visits allow the doctor to determine whether your baby is growing and developing normally."
ANS: D The pediatrician uses well-baby checkups to observe for abnormalities, answer parental questions, give immunizations, and observe the normal growth and development of the infant. Checkups are done to allow for the pediatrician to identify problems, not for the mother to identify problems. The nurse can answer this question; it does not need to be answered by the pediatrician. Checkups are not required by law. PTS: 1 DIF: Cognitive Level: Application REF: 472 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance
5. Which is the treatment for miliaria? a. Application of oil b. Removal of wet clothing c. Removal of excess clothing d. Application of soothing lotion
ANS: C Miliaria (heat rash) develops in infants who are too warmly dressed. Oils and ointments should be avoided. Wet clothing is not the cause of miliaria. Lotion should be avoided. PTS: 1 DIF: Cognitive Level: Understanding REF: 471 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance
10. During the first 6 months of life, the infant should have well-baby checkups at which interval? a. 1 to 2 weeks b. 2 to 4 weeks c. 1 to 2 months d. 3 to 4 months
ANS: C Most pediatricians schedule well-baby checkups every 1 to 2 months (4 to 8 weeks) to assess the infant's growth and development, answer parental questions, observe for abnormalities, and give immunizations. Checkups are scheduled for every 1 to 2 months. Two to 4 weeks is too soon between visits, and 3 to 4 months is too long between checkups. PTS: 1 DIF: Cognitive Level: Understanding REF: 472 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance