Newborn/Infant Milestones PrepU
When performing neurological reflexes on the infant, which primitive reflex will be present longest? Moro Babinski step rooting
Babinski Explanation: 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.
Which activity is most beneficial in the development of the newborn? placement in an infant swing in a position to allow observation of the family's activities laying on his back with a mobile overhead being sung to by his mother listening to classical music
being sung to by his mother Explanation: 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.
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? "Look how cute she is." "Are you almost ready to be discharged?" "You should always hold your baby for feedings instead of propping the bottles." "Is she almost done feeding?"
"You should always hold your baby for feedings instead of propping the bottles." Explanation: 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.
The nurse is providing education about nutrition and feeding to the parents of a healthy 10-month-old child. What foods, if reported by the parents, indicate the need for further education? Select all that apply. pureed beef cooked peas honey rice cereal whole grapes
whole grapes honey Explanation: Grapes can be a choking hazard and should be cut up to reduce this risk. Honey has a risk of botulism and should not be provided to children under 1 year of age. The other foods are all appropriate choices for a child this age.
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 is still sleeping; I guess she is worn out." "She has been a chatterbox and smiles just like her brother." "She has been crying every time someone picks her up." "She is so quiet today; that is not like her."
"She has been a chatterbox and smiles just like her brother." Explanation: 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.
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? "By 1 year my baby should have about three teeth." "My baby's first tooth will likely appear between 5 and 6 months." "My baby will most likely have his upper middle teeth come in first." "The first teeth that will likely appear are the lower incisors."
"The first teeth that will likely appear are the lower incisors." Explanation: 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 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 plays an important role in overall oral health." "Drinking water is really all you need to do to rinse your child's mouth." "Toothpaste is not necessary; it is the scrubbing that is required." "That is great, infants typically hate toothpaste."
"Toothpaste is not necessary; it is the scrubbing that is required." Explanation: Toothpaste for infants is not required. The important health technique is the removing of plaque, and that is accomplished through scrubbing of the teeth.
When performing neurological reflexes on the infant, which primitive reflex will be present longest? step Babinski rooting Moro
Babinski Explanation: 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.
Which developmental milestone would the nurse expect an 11-month-old infant to have achieved? Sitting independently Building a tower of four cubes Walking independently Turning a doorknob
Sitting independently Explanation: 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 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 lateral gumline lower central gumline upper lateral gumline upper central gumline
lower central gumline Explanation: The lower central incisors are usually the first to appear, followed by the upper central incisors.
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? "Is he able to hold a pencil and scribble on paper?" "Does he move a toy back and forth from one hand to the other when you give it to him?" "Does he place toys into a box or container and take them out?" "Is he able to drink with a cup by himself?"
"Does he move a toy back and forth from one hand to the other when you give it to him?" Explanation: 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.
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? "I see you have a car seat. That is great." "With the car seat in front, you can keep an eye on your baby." "Let me go over car seat safety with you, so you can install your car seat properly." "You should never put the car seat in the front."
"Let me go over car seat safety with you, so you can install your car seat properly." Explanation: 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 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?" "Is he in pain?" "We will need to collect a stool specimen for analysis." "Grunting is normal with infant stool formation."
"What does his stool look like?" Explanation: 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 information provided.
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 5 oz (2.9 kg). Which response by the nurse is most appropriate? "Your infant's weight loss is within the expected range." "All infants lose a substantial amount of weight after birth." "Your infant has lost too much weight and may need to be hospitalized." "Your infant has lost a bit more than the normal amount."
"Your infant's weight loss is within the expected range." Explanation: The normal newborn may lose up to 10% of birth weight. This infant has lost 9.1%. 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 (2,950 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? 15 lb 4 oz (6920 g) 10 lb 8 oz (4760 g) 19 lb 8 oz (8825 g) 13 lb (5900 g)
19 lb 8 oz (8825 g) Explanation: The average newborn weighs 7.5 lb (3400 g). The average newborn loses 10% of birth weight over the first week of life but regains it in about 10 to 14 days. Most infants double their birth weight by 4 to 6 months of age and triple their birth weight by the time they are 1 year old. If the newborn weighed 6 lb 8 oz (2,950 g) at birth and tripled that weight at 12 months, the infant should weigh 19 lb 8 oz (6.5 lb × 3 = 19.5 lb) or 8825 g.
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) 20 lb (9.1 kg) and 28 inches (70 cm) 28 pounds (12.7 kg) and 32 inches (80 cm) 16 lb (7.2 kg) and 26 inches (65 cm)
24 pounds (10.8 kg) and 30 inches (75 cm) Explanation: 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.
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? 28 pounds (12.7 kg) and 32 inches (80 cm) 16 lb (7.2 kg) and 26 inches (65 cm) 24 pounds (10.8 kg) and 30 inches (75 cm) 20 lb (9.1 kg) and 28 inches (70 cm)
24 pounds (10.8 kg) and 30 inches (75 cm) Explanation: 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.
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? 29 in (74 cm) 32 in (81 cm) 27.5 in (70 cm) 30.5 in (77.5 cm)
27.5 in (70 cm) Explanation: 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 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 Never use soap on an infant's hair Infants need a daily bath Soap lubricates and oils an infant's skin
Bath time provides an opportunity for play Explanation: 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 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. Only small pillows should be used in cribs. A safe temperature for hot water heaters in households with infants is 120°F (48.9°C). Car seats should be placed in back seats. Bottle should only be propped for infants 8 months or older.
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). Explanation: 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 nurse is assessing the 18-month-old infant. The nurse notes the anterior fontanel (fontanelle) has closed. What initial action by the nurse is indicated? Review the birth records of the infant to see if there were any other anomalies. Document the findings as normal. Notify the infant's health care provider. Measure the infant's head circumference.
Document the findings as normal. Explanation: The anterior fontanel (fontanelle) most often closes between 12 and 24 months of age. The closure of the fontanel (fontanelle) at 18 months of age does not signal any health issues for the infant.
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? Vitamin E Iron Vitamin D Calcium
Iron Explanation: 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.
An infant is breastfed. When assessing the stools, which findings would be typical? Less constipation than bottle-fed infants Harder stools than those of bottle-fed infants A strong odor Fewer stools than bottle-fed infants
Less constipation than bottle-fed infants Explanation: 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 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. Sitting ability and the age of first tooth eruption are correlated. Most infants sit steadily at 4 months; this infant is normal. Most infants sit steadily at 3 months; this infant is slightly delayed.
Most infants do not sit steadily until 8 months; this infant is normal. Explanation: 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.
What feeding practice used by the parents of an 8-month-old should the nurse discourage? Continuing to offer foods the child rejects. Including the infant at family meals in her high chair. Placing all liquids given the child in a "no spill" sippy cup. Giving the child soft table food and finger foods.
Placing all liquids given the child in a "no spill" sippy cup. Explanation: No-spill sippy cups promote sucking rather than teach cup drinking. Reserve these for times when avoiding spills is a must. The other feeding practices are age appropriate and safe. Soft table food and finger foods promote accepting new textures and self-feeding. Reoffering rejected food allows the child to accept it when ready. Including the infant at the family table provides for modeling of eating behaviors and socialization.
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? Read age-appropriate books to the infant daily. Respond promptly when the infant cries. Praise the infant when a new milestone is reached. Appropriately enunciate words when speaking to the infant.
Respond promptly when the infant cries. Explanation: The developmental task of the infant year, according to Erikson, is to gain a sense of trust. This can be accomplished by promptly meeting the infant's needs during the first year of life. If the infant does not learn to trust, mistrust will develop. Praising will help meet the future developmental tasks of the child. Reading books and appropriately enunciating words will aid in the infant's language development.
Which milestone would the nurse expect an infant to accomplish by 8 months of age? Sitting without support Pulling self to a standing position Being able to sit from a standing position Creeping on all fours
Sitting without support Explanation: 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 assessing a 12-week-old infant in the clinic at a well-baby visit. Which assessment finding does the nurse predict to assess in this healthy infant? Smiles at significant others Bears weight on legs when held in standing position Able to sit up and roll over Grasps objects and brings them to the mouth
Smiles at significant others Explanation: By 12 weeks of age the infant smiles at their mother and significant others. The other choices are seen in the infant who is about 20 weeks of age.
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 laughs aloud and responds to name. The infant raises head and chest while on stomach. The infant stays seated in the tripod position. The infant transfers objects from one hand to the other.
The infant raises head and chest while on stomach. Explanation: Infants have gained some neck control and can independently raise head and chest by 2 months of age. Transferring objects from one hand to another is expected at 7 months of age. Laughing aloud and responding to his or her name is expected between 4 to 5 months of age. Sitting in the tripod position is not expected until 6 months of age.
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 should have a referral for a neuromuscular assessment. The child should be provided with a baby seat to support the sitting position. The child's stability will progress to independent sitting over the upcoming months. The child is progressing well on other milestones so there's no cause for worry.
The child's stability will progress to independent sitting over the upcoming months. Explanation: It is a normal finding for the 6-month-old child to be shaky and fall over when learning to sit and for the child to often only sit with a "tripod" sit supported by the hands. No further assessment or support is needed.
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 is unable string together 2 word sentences. The infant has frequent episodes of crossed eyes. The infant seems disinterested in the surrounding environment. The infant does not pay attention to noises behind him. The infant babbles.
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. Explanation: 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.
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 infant's eyes are partially open and there are small movements in the extremities. The newborn's eyes are open and no body movements are noted. The newborn's eyes are open and he is smacking his lips. The infant is awake but appears drowsy.
The newborn's eyes are open and no body movements are noted. Explanation: 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.
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? An infant at this age should have regular respirations. The normal respiratory rate for an infant at this age is between 20 and 30 breaths per minute. The irregularity of the infant's respirations are concerning; I will notify the physician. The respirations of a 1-month-old infant are normally irregular and periodically pause.
The respirations of a 1-month-old infant are normally irregular and periodically pause. Explanation: 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 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? The child has a regular, scheduled bedtime. They put her to bed when she falls asleep. They sing to her before she goes to sleep. If she is safe, they lie her down and leave.
They put her to bed when she falls asleep. Explanation: 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.
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 sing to her before she goes to sleep. If she is safe, they lie her down and leave. The child has a regular, scheduled bedtime. They put her to bed when she falls asleep.
They put her to bed when she falls asleep. Explanation: 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.
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 infant begins to eat fruit by 12 months of age as soon as the first tooth erupts when weaning is complete
as soon as the first tooth erupts Explanation: 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? have many "blue" or moody periods develop a fear of strangers insist on things being done the infant's way be able to turn over onto the back
be able to turn over onto the back Explanation: 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; a 4-month-old infant has not developed emotionally to have "moody" periods and is dependent on parental care.
The nurse is educating the mother of a 6-month-old boy about the symptoms for teething. Which symptom would the nurse identify? running a mild fever or vomiting choosing soft foods over hard foods increased biting and sucking frequent loose stools
increased biting and sucking Explanation: 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.
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: shaking a rattle to enjoy the sound. pushing a spoon from her high chair tray to the floor. smiling at herself in the mirror. looking for a toy in her crib at the last place she saw it.
looking for a toy in her crib at the last place she saw it. Explanation: 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.
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 the expected amount for age. the weight assessment is blatantly inaccurate. the child weighs less than expected for age. the child weighs more than expected for age.
the child weighs less than expected for age. Explanation: Birth weight should triple by 12 months. The child should weigh near 24 pounds 12 ounces (11250 g). The child is underweight for age.
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) weight of 14 lb (6400 g) and length of 24 in (61.0 cm) weight of 18 lb (8200 g) and length of 28 in (71.1 cm) weight of 20 lb (9100 g) and length of 30 in (76.2 cm)
weight of 16 lb (7300 g) and length of 26 in (66.0 cm) Explanation: The average newborn weighs 7.5 lb (3400 kg) at birth. Most infants double their birth weight at 4 to 5 months and will triple by the time they are 1 year old. If this infant was 8 lb (3600 kg) at birth, then it is most likely now 16 lb (7300 g). The average newborn is 20 in (50 cm) long at birth. They grow more quickly in length over the first 6 months, than during the second 6 months. By 12 months of age, the infant's length has increase by 50%. At 1 year, this infant will most likely be 30 in (76.2 cm) in length; however, since most of the growth occurs in the first 6 months, it is possible for the infant to grow an additional 6 in (15 cm) during that time.
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." "Giving a bottle of milk when the infant goes to bed can lead to obesity." "Giving your baby a pacifier at bedtime will satisfy the need to suck." "You could occasionally give your baby a bottle of water at bedtime."
"Bottles given at bedtime can cause erosion of the enamel on the teeth." Explanation: 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.
The student nurse is reviewing the records of a pediatric client. Which statement about the client's progress indicates the need for further instruction? "Both growth and development are influenced by heredity." "Maturation refers to the child's increases in body size." "Development refers to the increase in skills the child demonstrates as they grow and age." "Increases in body size are referred to as growth."
"Maturation refers to the child's increases in body size." Explanation: 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.
Stacy is going to visit her son in the intensive care unit. She has been pumping breast milk and storing it in the fridge. Stacy is making her son's bottle for his feeding and goes to warm the breast milk. What option should the nurse give the mom to prepare the bottle? "Just use the microwave in our kitchen." "It is okay if the frozen milk is in the bottle." "You can use the hot water tap to get warm water to warm the bottle." "Just take the bottle from the fridge and use it."
"You can use the hot water tap to get warm water to warm the bottle." Explanation: The nurse should recommend using warm water or a warm-water tap to place the bottle in before feeding. A microwave should never be used; it could create hot spots and burn the infant. The other choices are not recommended and can cause stomach discomfort.
The nurse assesses a 4-month-old child during a well-child visit (above). Which assessment finding should the nurse report to the primary health care provider? waking 3 times per night to feed occasionally spitting up after breastfeeding not rolling over not smiling or tracking faces
not smiling or tracking faces Explanation: Preterm infants should be assessed developmentally based on their corrected age. For a 2-month-old infant, corrected waking at night, spitting up, and not rolling over are all normal findings. Not smiling or tracking faces are concerning findings that could indicate problems with vision. This requires follow-up by the health care provider.
The nurse is educating the mother of a newborn about feeding practices. The nurse correctly advises the mother that: most newborns need to eat about 4 times per day. the newborn's stomach can hold between 0.5 oz and 1 oz. the best feeding schedule offers food every 4 to 6 hours. demand scheduled feeding is associated with increased difficulty getting the baby to sleep through the night.
the newborn's stomach can hold between 0.5 oz and 1 oz. Explanation: The capacity of the normal newborn's stomach is between 0.5 oz and 1 oz. 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 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 laugh out loud within the next month." "I can expect my infant to become clingy around strangers within the next month." "I can expect my infant to be able to raise the head up when on the stomach within the next month." "I can expect my infant to be able to hold a rattle within the next month."
"I can expect my infant to be able to raise the head up when on the stomach within the next month." Explanation: It is expected that a 3-month-old infant can raise the head to 45 degrees while laying on the stomach. Becoming clingy around strangers occurs in the infant around 6 to 8 months of age. The infant can begin to hold a rattle around 5 months of age. At 4 to 5 months, the infant will typically begin to laugh out loud.
What is the correct amount of wet diapers a mature infant should produce each day? An infant should have 9 to 10 wet diapers/day. An infant should have 6 to 8 wet diapers/day. An infant should have 3 to 5 wet diapers/day. An infant should have 1 to 2 wet diapers/day.
An infant should have 6 to 8 wet diapers/day. Explanation: 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 caregivers of an infant state that their child cries when her mother leaves for even a short amount of time. What might the nurse suggest as a way to console the infant and develop a sense of security when the child's primary caregiver is out of sight? Give her dolls and stuffed animals so she learns to distract herself. Pick the child up as soon as she begins to cry. Play peek-a-boo with the child when happy. Slowly increase the amount of time allowed to cry before being picked up.
Play peek-a-boo with the child when happy. Explanation: For the infant, self-assurance is necessary to confirm that objects and people do not cease to exist when out of sight. This is a learning experience on which the infant's entire attitude toward life depends. The ancient game of "peek-a-boo" is a universal example of this learning technique. It is also one of the joys of infancy as the child affirms the ability to control the disappearance and reappearance of self. In the same manner by which the infant affirms self-existence, she learns to confirm the existence of others, even when they are temporarily out of sight.
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) 15 lb 4 oz (6920 g) 10 lb 8 oz (4760 g) 13 lb (5900 g)
19 lb 8 oz (8825 g) Explanation: The average newborn weighs 7.5 lb (3400 g). The average newborn loses 10% of birth weight over the first week of life but regains it in about 10 to 14 days. Most infants double their birth weight by 4 to 6 months of age and triple their birth weight by the time they are 1 year old. If the newborn weighed 6 lb 8 oz (2,950 g) at birth and tripled that weight at 12 months, the infant should weigh 19 lb 8 oz (6.5 lb × 3 = 19.5 lb) or 8825 g.
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? "We will need to check this out since any delays related to prematurity should be resolved by the time a child is 6 months old." "All children mature and develop at different rates so it is unwise to compare them in this way." "You should talk with the doctor about getting your son tested." "Delays are normal when a child is premature."
"Delays are normal when a child is premature." Explanation: 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 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. "I try to eat healthy in front of my daughter so she will hopefully pick up good eating habits." "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." "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 plan on encouraging my son to cook with me when he is old enough so that he will enjoy a variety of foods and learn how to cook too."
"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." Explanation: 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.
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? "Maybe she just knows your voice better than your mother's." "Babies really can't tell the difference between people at that age." "You may be right, since infants can sense their mother's smell as early as 7 days old." "I'm not sure a 4-week-old infant can tell their mother from another woman's smell."
"You may be right, since infants can sense their mother's smell as early as 7 days old." Explanation: 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 caring for a parent following the birth of the newborn. The new parent asks the nurse, "When is the best time for me to start bonding with my baby?" Which response by the nurse is appropriate? "Newborns prefer to have verbal interaction as they enter a drowsy state." "You should interact with your newborn when the eyes are open wide and bright." "When newborns begin to cry, they are in need of parental interaction." "Interaction has the best effect on bonding when the newborn is in a quiet sleep state."
"You should interact with your newborn when the eyes are open wide and bright." Explanation: A newborn's neurological development includes 6 states of consciousness. The best time for a family to interact with a newborn is when the newborn is in the quiet or active alert stage. The quiet alert state is when the body is calm and the eyes are wide open. The active alert state is when the eyes are wide open and there are body movements. Examples of this are minimal body activity, regular respirations, face with shiny look, eyes wide and bright, and paying attention to stimuli. When the newborn is crying it is very difficult to get the newborn's attention. The newborn needs immediate needs met at this time such as feeding, repositioning, or a diaper change. When the newborn is in a drowsy state, trying to interact only causes frustration for the newborn as sleep is interrupted.
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. Read age-appropriate books to the infant daily. Praise the infant when a new milestone is reached. Appropriately enunciate words when speaking to the infant.
Respond promptly when the infant cries. Explanation: The developmental task of the infant year, according to Erikson, is to gain a sense of trust. This can be accomplished by promptly meeting the infant's needs during the first year of life. If the infant does not learn to trust, mistrust will develop. Praising will help meet the future developmental tasks of the child. Reading books and appropriately enunciating words will aid in the infant's language development.
A parent asks the nurse what symptoms to expect with normal teething in the infant. How should the nurse respond? The infant's gumline will be tender. The infant's temperature may go as high as 102°F (38.9°C). The infant will be constipated for 2 days. The infant will not play or eat for 2 days.
The infant's gumline will be tender. Explanation: Infants experience discomfort as the tooth emerges through the periodontal membrane and from inflammation. When teething, some infants become irritable, have excessive drooling, and like to bite on hard surfaces. To relieve discomfort, the parent can apply ice to the gums or use an over-the-counter topical anesthetic for infants. Some infants will refuse to eat or have poor sleeping due to the pain in the gums. There is not a definitive time frame for this to occur, and it does not happen in all infants. Fever, diarrhea, and vomiting are signs of illness, not teething.
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 weight assessment is blatantly inaccurate. the child weighs less than expected for age. the child weighs the expected amount for age. the child weighs more than expected for age.
the child weighs less than expected for age. Explanation: Birth weight should triple by 12 months. The child should weigh near 24 pounds 12 ounces (11250 g). The child is underweight for age.
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 10-week-old the growth of a 2-month-old the growth of a 5-month-old the development of a 3-month-old
the development of a 3-month-old Explanation: 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 examining an 8-month-old girl for appropriate development during a regular check-up. Which observation points to a developmental risk? Cannot pull self to standing Uses only the left hand to grasp Picks up small objects using entire hand Crawls with stomach down
Uses only the left hand to grasp Explanation: 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.
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 not cleaning the infant's gums after eating meals or snacks brushing the infant's teeth with fluoride-free toothpaste using a cloth instead of a brush for cleaning the infant's teeth
putting the infant to bed with a bottle of milk or juice Explanation: 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.
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 20 lb (9100 g) and length of 30 in (76.2 cm) weight of 14 lb (6400 g) and length of 24 in (61.0 cm) weight of 18 lb (8200 g) and length of 28 in (71.1 cm) weight of 16 lb (7300 g) and length of 26 in (66.0 cm)
weight of 16 lb (7300 g) and length of 26 in (66.0 cm) Explanation: The average newborn weighs 7.5 lb (3400 kg) at birth. Most infants double their birth weight at 4 to 5 months and will triple by the time they are 1 year old. If this infant was 8 lb (3600 kg) at birth, then it is most likely now 16 lb (7300 g). The average newborn is 20 in (50 cm) long at birth. They grow more quickly in length over the first 6 months, than during the second 6 months. By 12 months of age, the infant's length has increase by 50%. At 1 year, this infant will most likely be 30 in (76.2 cm) in length; however, since most of the growth occurs in the first 6 months, it is possible for the infant to grow an additional 6 in (15 cm) during that time.
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." "Make sure that you test the milk on your wrist before feeding." "You should only give fresh breast milk to an infant." "Breast milk can be given cold, so there is no need to heat it."
"You should warm the milk under warm water instead." Explanation: A microwave can heat unevenly and cause burns and therefore should never be used to heat breast milk or formula for an infant. In addition, it can change the immune properties of the breast milk.
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? Readiness for enhanced nutrition, related to the age of the infant Imbalanced nutrition, more than body requirements, related to introduction of a high-calorie food Risk for aspiration related to feeding the infant an inappropriate food Imbalanced nutrition, less than body requirements, related to introduction of a low nutritive food
Risk for aspiration related to feeding the infant an inappropriate food Explanation: Children under about 5 years should not be offered popcorn or peanuts because of the danger of aspiration. This should be the primary nursing diagnosis because aspiration is the greatest danger to the infant in this scenario. Because the infant is receiving all the nutrition she needs from breastfeeding and because unbuttered popcorn is not a high-calorie food, imbalanced nutrition is not really a concern here. There is not a strong indication at this point that the infant is ready for enhanced nutrition, as the breast milk provides all of the nutrients she needs and as she appears to be satisfied after her feedings.
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. Educating the parents about when colic stops. Watching how the parents respond to the child. Assessing the parents' care and feeding skills.
Urging the baby's mother to take time for herself away from the child. Explanation: 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.
The nurse is educating the parents of a newborn prior to discharge home. The parents demonstrate teaching was successful when making which statement(s)? Select all that apply. "I understand it is normal for newborns to lose 5% to 10% of their bodyweight after birth." "I plan to add a little rice cereal to my breast milk so my newborn will sleep longer at night." "I will not be concerned if my newborn has stools that begin to have a yellowish color to them." "My newborn can see up-close things, like our faces, better than things at a distance." "We should get some rest in about 1 month when the newborn starts sleeping through the night."
"I will not be concerned if my newborn has stools that begin to have a yellowish color to them." "I understand it is normal for newborns to lose 5% to 10% of their bodyweight after birth." "My newborn can see up-close things, like our faces, better than things at a distance." Explanation: Newborn stools will become yellowish in color after the first few days of life. Newborns typically lose 5% to 10% of their birthweight the first few days of life, and begin to gain weight after this period. Newborns have better up-close vision and begin to recognize human faces during their newborn stage. Most infants will not sleep through the night until about 3 months of age. There is no evidence that rice cereal keeps a newborn from waking and the practice of feeding rice cereal to newborns is discouraged by physicians as the newborn needs formula or breast milk specifically.
A client who is breastfeeding asks the nurse if she can give the newborn a pacifier. Which nursing response is most appropriate? "I know a lot of people who breastfed and also gave their newborns a pacifier." "This decision should be made by you and your partner based on your personal preferences." "It is recommended to wait until breastfeeding is well-established before introducing a pacifier." "I will request the lactation consultant come talk to you about pacifier usage while breastfeeding."
"It is recommended to wait until breastfeeding is well-established before introducing a pacifier." Explanation: It is recommended to wait to introduce a pacifier once breastfeeding is well-established, which can take about 1 month. This is to limit nipple confusion and promote an adequate milk supply. Stating other people have done this does not provide education to the client, nor does it address this specific client's situation. While the decision is up to the newborn's parents, this response does not address the client's concern. Requesting a lactation consultant come does not address the client at this moment. The nurse can provide education now, and also request the consultant for follow-up information.
A first-time mother, who is breastfeeding, phones the clinic nurse because she is concerned about her 3-month-old infant's stools. Which statement by the mother would alert the nurse to contact the health care provider? "The stools are loose and seedy." "The stools are small and hard." "My infant has not had a bowel movement in almost 8 hours." "My infant grunts and squirms when having a bowel movement."
"The stools are small and hard." Explanation: The breastfed infant has stools that appear yellow and seedy. Consistency of stool is more important than frequency. Small, hard stools are a concern, and the infant should be evaluated for gastrointestinal issues. The nurse will contact health care provider. It is normal for infants to appear to have difficulty with bowel movements because the gastrointestinal system is still immature. It is common for infants to go several days without having a bowel movement.
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 states her baby looks too warm, so she is moving the bassinet in front of the air conditioner to cool him off. A mother places her newborn on its side after falling asleep. A mother places the baby comforter her grandmother made over the newborn's body. A mother states all of her children like sleeping on their abdomen and this newborn likes it too. A mother tells her husband to be sure to place the newborn on his back when putting the baby in the bassinet.
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. Explanation: 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
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? Put the baby to bed at various times of the evening. Let the baby cry during the night and she will eventually fall back to sleep. Use the crib for sleeping only, not for play activities. Wake the baby from afternoon naps after 1 hour to ensure she is sleepy by nighttime.
Use the crib for sleeping only, not for play activities. Explanation: 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.
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? Wake the baby from afternoon naps after 1 hour to ensure she is sleepy by nighttime. Let the baby cry during the night and she will eventually fall back to sleep. Put the baby to bed at various times of the evening. Use the crib for sleeping only, not for play activities.
Use the crib for sleeping only, not for play activities. Explanation: 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.
A client's caregivers ask the nurse about good choices for solid foods for their 10-month-old child. The caregivers are lacto-ovo vegetarian and wish to raise their child with the same diet. What food(s) will the nurse recommend? Select all that apply. yogurt or cottage cheese pureed chicken cooked egg yolk iron-fortified infant cereals unsalted nuts
iron-fortified infant cereals cooked egg yolk yogurt or cottage cheese Explanation: Iron-fortified cereals and egg yolk provide good sources of iron. Egg yolk and yogurt/cottage cheese provide protein. All of these are appropriate choices for a child this age. Pureed chicken is not appropriate for a vegetarian diet, and nuts are a choking hazard and not appropriate for a 10-month-old child.
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: is a protective reflex and retained for life. should be pronounced and easy to elicit. is expected to appear within 1 month. should have disappeared.
should have disappeared. Explanation: This primitive (not protective) reflex should be present at birth and disappear around age 4 months.
