Test 1 - PEDS

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

A 12-month-old infant with a blood pressure of 60/40 mm Hg Rationale: The nurse will first assess the 12-month-old infant with a blood pressure of 60/40 mm Hg. This is the expected blood pressure in an infant; however, by 12 months of age the blood pressure should rise to around 100/60 mm Hg. The normal respiratory rate of an infant is 30 to 60 breaths/minute. It is expected for a 1-month-old infant to still have Moro and rooting reflexes. These should diminish over the first few months of life. Stools are dark green to black and sticky for the first few days of life.

The parents of a 30-month-old toddler have brought the toddler into the emergency department because of a seizure. During the health history, the nurse learns that the toddler was frustrated and angry immediately preceding the seizure. The nurse suspects the toddler had a breath-holding spell. Which parental report suggests breath-holding?

A tantrum preceding the event Rationale: Temper tantrums are the natural result of frustrations that toddlers experience. They continue to occur until the toddler is old enough to verbalize feelings. The fact that there was a precipitating event of frustration and anger points to the likelihood that this is a cyanotic breath-holding spell. Breath-holding spells never occur during sleep, nor do they feature postictal confusion. Unconsciousness is not definitive because it is common to both seizures and breath-holding spells.

What advice should the nurse provide the parent of a toddler, regarding how to handle temper tantrums?

Appear to ignore the toddler Rationale: Temper tantrums are the natural result of frustration that toddlers have. Toddlers do not behave badly on purpose. They need time and maturity to learn the rules and regulations. During a temper tantrum, the advice is for the parent to ignore the behavior but ensure the toddler is safe. Rewarding temper tantrums can teach the toddler that tantrums are an effective method of interaction. Ignoring tantrums teaches the toddler that tantrums are ineffective. The parent needs to use self-control when dealing with a temper tantrum. This is a way to model acceptable behavior for the toddler.

When performing neurological reflexes on the infant, which primitive reflex will be present longest?

Babinski Rationale: 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.

What information would the nurse include when teaching the parents of an infant about colic?

Colic symptoms will probably fade at 3 months of age. Rationale: Colic is defined as inconsolable crying that lasts 3 hours or longer per day and which it has no physical cause. Colic symptoms typically fade around 3 months of age. This is an age when infants are better able to console themselves. Colic can be very stressful for parents and lead to sleep deprivation. Many infants need to be carried at all times to reduce crying. Some do well with non-nutritive sucking and others need white noise or motion to help them soothe. Because colic has no physical cause, telling the parents about follow up for "nervous stomach" is not necessary. The infant should be placed in a position of comfort to reduce the crying. Every infant has his or her own position that helps; don't just place the infant on his or her back. Doubling up the formula will not help colic and may actually cause more problems because it can cause abdominal pain and increased weight gain.

The nurse is playing a game with a toddler in the hospital room. What is the most important benefit of this nurse-client interaction?

Developing a trusting relationship with the nurse. Rationale: While all of these are benefits of playing a game with the child, the most important benefit is establishing a relationship with the client. This will help the child to be less fearful in an unfamiliar environment and foster a better treatment and recovery period while hospitalized

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." Rationale: 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 parents of an overweight 2-year-old boy admit that their child is a bit "chubby," but argue that he is a picky eater who will eat only junk food. Which response by the nurse is best to facilitate a healthier diet?

"Give him more healthy choices with less junk food available." Rationale: Suggesting that the parents transition the child to a healthier diet by serving him more healthy choices along with smaller portions of junk food will reassure them that they are not starving their child. The parents would have less success with an abrupt change to healthy foods. Explaining calorie requirements and the timeline for acceptance of a new food does not offer a practical reason for making a change in diet.

The nurse is preparing to catheterize an 11-year-old child. The nurse correctly recognizes the child's approximate bladder capacity is what amount?

- 13 ounces Rationale: The formula for bladder capacity is age in years plus 2 ounces. If a child is 11 years of age, this would be approximately 13 ounces.

A nurse is assessing a 2-year-old's language development. What would the nurse expect to assess?

Use of a two-word noun-verb sentence Rationale: A 2-year-old should be able to say a two-word sentence that consists of a noun and verb. A 15-month-old can say 4 to 6 words. A 30-month-old knows his full name and can name one color.

A 12-month-old seen at a walk-in clinic weighed 8 pounds 4 ounces (3750 g) at birth. Weight now is 20 pounds 8 ounces (9300 g). The nurse determines:

the child weighs less than expected for age. Rationale: Birth weight should triple by 12 months. The child should weigh near 24 pounds 12 ounces (11250 g). The child is underweight for age.

After the nurse provides education to new parents about appropriate sleeping habits for infants, which statement by a parent would indicate to the nurse that teaching needs to reoccur?

"My husband gave the baby a special bear that I will place in the crib." Rationale: The nurse should reinforce that stuffed animals, blankets, pillows, and soft mattresses are suffocation hazards for infants.

The parents of a 3-year-old boy have asked the nurse for advice about a preschool for their child. Which suggestion is most important for the nurse to make?

"The staff should be trained in early childhood development." Rationale: The nurse would recommend a preschool where the staff is trained in early childhood development and cardiopulmonary resuscitation. Cleanliness and a loving staff are not enough without competence. Good hygiene procedures require that a sick child not be allowed to attend. It is also important that parents are allowed to visit any time without an appointment.

The nurse conducting a 6-month well-baby check-up assesses for the presence/absence of the asymmetric tonic neck reflex. At this age the reflex:

should have disappeared. Rationale: This primitive (not protective) reflex should be present at birth and disappear around age 4 months.

The nurse is assessing the language development of a 3-year-old girl. Which finding would suggest a problem?

speaks in 2- to 3-word sentences Rationale: If the child is still speaking telegraphically in only 2- to 3-word sentences, it suggests there is a language development problem. If the child makes simple conversation, tells about something that happened in the past, or tells the nurse her name she is meeting developmental milestones for language.

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 3-month-old Rationale: 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 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) Rationale: 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 nurse is assessing the newborn. Which would the nurse assess to be an abnormal finding?

Natal teeth noted in the mouth that are loose Rationale: The presence of 1 or 2 teeth at birth (natal teeth) is a finding that may be benign or may point to other congenital abnormalities. The neck should be short, thick and mobile. The gluteal folds should be symmetrical. It is normal for the newborn to startle to loud sounds.

A 9-month-old has been brought to the clinic for a well-child visit. The mother reports her son was born 6 weeks prematurely. During the data collection, the child's mother reports her son seems to be a few months "behind" what she recalls from her older children. What is the best response by the nurse?

"Delays are normal when a child is premature." Rationale: 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 parents of an 8-month-old boy voice concern to the nurse that their child is not developing motor skills as he should. What question would be appropriate for the nurse to ask in determining if their fears are warranted?

"Does he move a toy back and forth from one hand to the other when you give it to him?" Rationale: 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.

The father of a 6-week-old infant voices concerns about his son's stooling. He further shares that his son grunts and cries when having a bowel movement. What response by the nurse is mostappropriate?

"What does his stool look like?" Rationale: 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 nurse goes in to check on a new mother to see how breastfeeding is going with her new son. The nurse observes the infant is on the mother's lap with the blanket unwrapped, and the mother is washing his face, and gently stroking the baby. The mother has had trouble breastfeeding the last few times. What is the appropriate response from the nurse?

"You are doing a wonderful job attempting to wake the baby." Rationale: The nurse should be emotionally supportive to the new mom. The mom's techniques are commonly used in breastfed infants who are sleeping. The encouragement from the nurse will support the mom through this learning period. The other responses do not emotionally support the mom or contribute to a positive learning environment.

A nurse is presenting a class on toilet training to a group of parents with toddlers. Which information would the nurse include in the class? Select all that apply.

-Using training pants that slide down easily and quickly -Praising the child when he or she urinates or defecates -Putting the child on the potty chair at regular intervals during the day Rationale: For effective toilet training, parents should allow 1 to 2 weeks to psychologically prepare the child for training, using training pants that slide down easily and quickly, praising the child when he or she urinates or defecates, limiting the time spent on the potty chair to no longer than 10 minutes (or less if the child is resistant), and putting the child on the potty chair at regular intervals during the day.

A newborn requires skin care that includes bathing. Besides hygiene, what is another reason for bathing the newborn?

Bathing is a time for bonding with the parents. Rationale: The parents can use bath time for bonding with their newborn. This can be done with talking, cooing, and singing. Bath time should be slow-paced and nonstressful. Newborns prefer interacting with parents over toys and they love to watch people's faces. Bathing can help prevent infection, but it is a secondary response. Using soaps on the skin tends to dry the skin, not moisten it. After bathing, lotion can be applied. It is soothing to the baby and keeps the skin softened.

A 13-month-old child is brought to the clinic for a well-child visit. The child's parent expresses concern that the child has not started to walk yet. What is the best action should the nurse take?

Explain that children can take their first steps as late as 18 months of age. Rationale: Infants can begin walking as early as 8 to 9 months and as late as 18 months of age. Telling the parent that the child will start walking any day is true but not guaranteed. Asking if the child has been ill recently is an appropriate question during a well-child visit but does not address the parent's concerns. Since the child is on track developmentally, there is no indication to refer the child to a developmental specialist.

The mother of a 1-month-old infant voices concern about her baby's respirations. She states they are rapid and irregular. Which information should the nurse provide?

The respirations of a 1-month-old infant are normally irregular and periodically pause. Rationale: 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 parent of an infant asks the nurse when to begin brushing the infant's teeth. What would be the nurse's best response?

as soon as the first tooth erupts Rationale: 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.

The nurse is discussing sensory development with the mother of a 2-year-old boy. Which parental comment suggests the child may have a sensory problem?

"He doesn't respond if I wave to him." Rationale: The fact that the child does not respond when the mother waves to him suggests he may have a vision problem. The toddler's sense of smell is still developing, so he may not be affected by odors. Their sense of taste is not well developed either, and this allows him to eat or drink poisons without concern. The child's crying at a sudden noise assures the nurse that his hearing is adequate.

The nurse is providing anticipatory guidance to the parent of a 2-month-old infant in relation to growth and development. Which statement from the parent demonstrates proper understanding?

"I can expect my infant to be able to raise the head up when on the stomach within the next month." Rationale: 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.

After teaching the mother of a 13-month-old boy about suggestions for bathing and hygiene, the nurse determines that the teaching was successful when the mother states:

"It might be best to give him a bath in the evening." Rationale: The young child's increased activity level necessitates bathing daily or every other day. A good time to bathe the child is after eating, either after breakfast or in the evening. Hair is washed two to three times per week with a mild shampoo. Bubble baths should be avoided, to prevent urethral irritation and possible development of cystitis. Some children may have fears associated with bathing such as being afraid of being sucked down the plug hole. In this case, do not drain the tub until the child is out of the room.

The student nurse is reviewing the records of a pediatric client. Which statement about the client's progress indicates the need for further instruction?

"Maturation refers to the child's increases in body size." Rationale: 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?

"You can use the hot water tap to get warm water to warm the bottle." Rationale: 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 pediatric nurse is careful to monitor and assess the growth and development of all clients. Which characteristic should the nurse prepare to assess in the infants?

Grows and develops skills more rapidly than at any other time in their life Rationale: The infant grows and develops skills more rapidly than he or she ever will again. The toddler insists he or she can do things one minute and then becomes dependent the next minute. The preschool age child soaks in information and asks "why" and "how" over and over. The school-age child has a longer attention span and can become absorbed in a craft or activity for several hours.

The nurse is reviewing the diet of an 8-month-old infant with the mother who reveals she has been using evaporated milk to make the formula. Which additional ingredient should the nurse ensure she is including in the formula?

Iron Rationale: 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.

The nurse is caring for a 4-year-old girl following an appendectomy. The girl becomes fearful and starts to cry as soon as the nurse walks into the room. When the nurse asks about the crying, the girl says, "Nurses who wear shirts with flowers give shots." The nurse understands that this statement is an example of:

Transduction Rationale: The nurse identifies transduction. Because the 4-year-old recently received an injection from a nurse in a flowered uniform, the girl believes that all nurses who wear flowered uniforms give shots. Transduction is reasoning by viewing one situation as the basis for another situation even though the two may or may not be causally linked. Magical thinking involves believing that one's thoughts are all-powerful. Animism is attributing life-like characteristics to inanimate objects. Empathy is the understanding of others' feelings.

Parents and their nearly 3-year-old child have returned to the clinic for a follow-up appointment. Which of the findings may signal a speech delay?

Uses two-word sentences or phrases Rationale: A child nearly 3 years of age should speak in three- to four-word sentences. The other findings indicate normal expressive language for the age.

A parent tells the nurse that no matter what is asked of the toddler, the toddler says, "No." What suggestion might the nurse make to help the parent handle this situation?

give the toddler secondary, not primary, choices Rationale: Encouraging toddlers to express their opinion aids in developing a sense of autonomy. By allowing secondary choices, it gives the toddler a sense of mastery. Telling the toddler not to say "No" again is unrealistic as this is a favorite word and reaction of the toddler as he or she develops autonomy to find one's "self." Pretending not to hear the toddler only leads to more frustration for the toddler and the parent. It is also unrealistic not to ask the toddler questions. There would not be two-way communication between the parent and the toddler.

A pediatric nurse is providing care to several children. The nurse is reviewing the assessment findings for each of the children. Which finding requires the nurse to intervene?

3-year-old preschool-aged child who goes up stairs on hands and knees Rationale: At 3 years of age, a child should be able to climb the stairs one step up at a time or using alternating feet. If the child can only go up on hands and knees, further evaluation is needed. At 9 months of age, an infant can pull oneself up to a standing position and sometimes is able to cruise around furniture or even walk. Toddlers begin to walk between 9 and 18 months of age. Toddler at 24 months of age engage in parallel play rather than cooperative play.

The nurse is assessing 2-year-old twins. The parent states, "My twins will not play together, only alongside each other." Which action will the nurse take first?

Explain that this is normal behavior for toddlers. Rationale: Playing beside one another is parallel play and typical of toddlerhood. The nurse would explain this is normal behavior for the twins and then document the finding. The nurse would not need to observe the twins at play or ask additional questions as this is an expected finding.

An infant is breastfed. When assessing the stools, which findings would be typical?

Less constipation than bottle-fed infants Rationale: 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. Rationale: 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.

The nurse is assessing the oral cavity of a 4-month-old infant. Which finding is consistent with a child of this age?

No teeth Rationale: Normally infants are not born with teeth. Occasionally there are one or more teeth at birth. These are termed natal teeth and are often associated with anomalies. The first primary teeth typically erupt between the ages of 6 and 8 months.

Nursing students are reviewing information about the cognitive development of preschoolers. The students demonstrate understanding of the information when they identify that a 3-year-old is in what stage as identified by Piaget?

Preoperational thought Rationale: A 3-year-old is in the preoperational stage according to Piaget. Primary circular reaction is seen in infants of 3 months. Coordination of secondary schema is seen in infants at age 10 months. Tertiary circular reaction is seen in toddlers between 12 and 15 months.

The nurse is examining a 3-year-old girl during a regular visit. Which finding would disclose a developmental delay in this child?

The child demonstrates separation anxiety. Rationale: The child should be past the stage of separation anxiety by age 3 years. Imitating actions, copying a circle on paper, and responding to single requests are developmentally appropriate.

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 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."

A group of students is reviewing material about ways parents can help to foster a child's self-esteem. The students demonstrate a need for additional studying when they identify which method as promoting self-esteem?

Limiting the choices and decisions that the child makes Rationale: To promote self-esteem, parents should praise the child's achievements, show respect and support to the child, allow the child to make decisions, listen to the child, and spend time with the child. The parents need to be a coach to the child rather than just a cheerleader who merely praises accomplishments.

The best way for an infant's parent to help the child complete the developmental task of the first year is to:

respond to the infant consistently. Rationale: The developmental task of an infant is gaining a sense of trust. The infant develops this sense from the caretakers who respond to the child's needs, such as feeding, changing diapers, being held. It is a continuous process. A sense of trust is difficult to learn if things are constantly changing. Consistently responding to an infant's needs helps to build a sense of trust. An infant is too young to have variability in caretakers. This causes mistrust. The parents or caretakers do not need a special time to talk to the infant each day. It should be done with each interaction. Providing too much stimulus before the infant develops gross motor skills causes frustration from the child and not enjoyment.

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?

"You should always hold your baby for feedings instead of propping the bottles." Rationale: 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.

A mother of a toddler asks the nurse, "How will I know that my daughter is ready for toilet training?" Which response by the nurse would be most appropriate?

"You'll probably notice that your daughter is uncomfortable in wet diapers." Rationale: The markers of readiness for toilet training are subtle, but as a rule, children are ready for toilet training when they begin to be uncomfortable in wet diapers. Although the rectal and urethral sphincters are mature by the end of the first year, children are not cognitively and socially ready. In fact, many children do not understand what is being asked of them until they are 2 or even 3 years old.

The parent of a 2-year-old client states it is the child's naptime. The child is refusing to take a nap and cries, "I have to put my babies to sleep first!" The parent states, "I am so sorry, I do not know what is wrong. My child does not act this way at home. My child has 2 baby dolls we rock to sleep each day at home before nap." Which response by the nurse is most appropriate?

"A 2-year-old child's behavior can be greatly altered if rituals are not maintained." Rationale: Ritualism employed by the young child to help develop security involves following routines that make rituals of even simple tasks. The child's self-esteem is built through familiarity with the daily routine. When these rituals are interrupted, the child's behavior can be negatively impacted, resulting in temper tantrums for 2-year-old children. The nurse can recommend someone bring the dolls to the hospital; however, the nurse first needs to address the parent's concern. Stating the child is "just acting out" does not address the parent's concern or current situation. There is nothing in the scenario indicating inconsistent discipline.

The mother of a newborn reports she does not think her baby likes his formula since he spits up after only taking a small amount. Which response by the nurse is most appropriate?

"Your baby's stomach is small and can only hold about 0.5 to 1 oz at birth." Rationale: At the time of birth, an infant's stomach can only hold 0.5 to 1 oz ounce. This will gradually increase. While it is true that the infant does not eat much, this does not meet the educational needs of the mother and is not the best response. Burping is a part of normal newborn feeding practices but is not the best response. There is no indication there is a milk intolerance from the information reported.

A 3-year-old child is hospitalized. The parents are concerned because the child is now refusing to use the potty and is wetting the bed even though the child has achieved toilet training. Which response by the nurse is most appropriate?

"Your child is experiencing regression as a result of stress." Rationale: Regression is a change from present behaviors to past developmental levels of behavior. This is a normal response among children during times of intense stress, such as a hospitalization or the birth of a new sibling. The nurse should not tell the parents not to worry. The child will not have to learn to use the toilet again. The behavior is already learned. Asking why is not a therapeutic form of communication and may cause the parents to become unnecessarily defensive.

A 2-month-old infant has inconsolable crying, is gassy, and constantly draws the legs up. It has been determined that the infant has colic. Which education will the nurse provide to the parents?

"You can try a pacifier, music, or carrying the baby to help stop crying." Rationale: Colic is defined as inconsolable crying that lasts at least 3 hours or longer per day. Colic can begin as early as 2 weeks and usually resolves itself by 3 months. Parents should take a stepwise approach to resolving colic. The first step is to make sure all the infant's needs are met. Then decrease any stimuli, use soothing techniques such as carrying the infant, swaddling, pacifiers, etc. Colic does not mean the infant is very hungry and needs to eat more frequently, and is not the result of improper feeding or burping.

A parent asks the nurse if the 2-month-old infant can have bananas yet. The nurse would respond and educate the parent on the nutrition stages of infants by which response?

"You can try bananas 2 or 3 months from now." Rationale: The nurse will educate the parent to wait 2 to 3 months, because solid foods are not recommended for infants at 2 months of age. The age of 4 to 6 months is when it is recommended to introduce solid foods. In 1 month, the infant will be only 3 month of age. The other responses will not help the parent determine the appropriate answer.

Two parents who have financial issues ask the nurse if a borrowed crib would be okay to use for their new twin boys. Which response should the nurse use in educating the parents?

"You can use the crib, but there are guidelines to follow." Rationale: The nurse would educate the parents on the latest guidelines for using baby cribs and provide them with available safety and information pamphlets. All cribs made after 1973 have specific safety guidelines and standards. The other responses do not provide the correct available information or educate the parents on safety standards.

During the first visit to the pediatrician's practice the nurse is performing an admission interview and assessment of a 4-week-old infant. The mother states, "I am sure my baby girl knows my smell because she is much more settled in my arms rather than my mother's arms when she is upset." What is an appropriate response by the nurse?

"You may be right, since infants can sense their mother's smell as early as 7 days old." Rationale: 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 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." Rationale: 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 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 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." Rationale: 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.

Anticipatory guidance for an infant for the 4th month should include the fact that the infant will be able to achieve which developmental milestone?

- Be able to turn over onto the back Rationale: 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 assessing the oral cavity of a 6-month-old child. When palpating the location in which the first primary teeth erupt, which location is being assessed?

- Lower Central Gumline Rationale: The lower central incisors are usually the first to appear, followed by the upper central incisors.

A stay-at-home father wants to purchase commercial toddler meals because his 16-month-old girl recently choked on table food. Which food items will the nurse suggest not be given to this child? Select all that apply.

- Round foods such as hot dogs, whole grapes, and cherry tomatoes - Hard foods such as nuts, raw carrots, and popcorn - Sticky foods like peanut butter alone, gummy candies, and marshmallows Rationale: To offer soft round foods safely, cut hot dogs in uneven pieces and cut grapes and cherry tomatoes into quarters. This prevents food impacting in an airway. Avoid the hard and sticky foods due to aspiration and airway occlusion risks. The cooked vegetables listed are safe as are the soft fruits.

A nurse, who is also a mother of a 2-year-old child, attends a party at a friend's house and notes some safety concerns that she would like to share with the other mother privately. Which observations during the party would be considered a safety concern that should be addressed privately when appropriate? Select all that apply.

- The nurse/mother notes that the toddler's car seat is located in the passenger front seat. - The parent is busy entertaining guests and did not notice the toddler running out in the neighborhood street to get a toy. - The parents allow the toddler to climb up on the counter and watch as food is stirred on the stove. Rationale: Toddlers' motor ability jumps ahead of their judgment. To prevent serious injury, the nurse should teach parents to be alert as to what their toddler is doing at all times (like climbing on a countertop next to a stove). Toddlers have no judgment concerning moving cars so they walk across streets with no regard for oncoming cars. Toddlers need to ride in a car seat with a five-point restraint placed in the back seat (not the front seat) so the child is not struck by the passenger seat airbag. Toddlers need to wear a helmet as soon as they begin riding a tricycle. Because they cannot swim well, parents need to check whether backyard pools—another area prone to unintended injury—are securely fenced.

The nurse is preparing the anticipatory guidance sheets that are provided to parents. When organizing the sheets, place the milestones in their proper sequence from earliest to latest.

1 - Creep up stairs 2 - Run and jump in place 3 - Engage in parallel play 4 - Name one color 5 - Zip up their own jackets

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) Rationale: 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) Rationale: 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?

27.5 in (70 cm) Rationale: 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 helping the mother of a 5-month-old boy understand the importance of developmentally appropriate play. Which one of the toys best meets the needs of this child?

A yellow rubber duck for the bath Rationale: The rubber duck is most appropriate. It is safe, visually stimulating while bobbing on the water, and adds pleasure to bath time. A push-pull toy promotes skill for a walking infant. Pots and pans from the kitchen cupboard are played with successfully after sitting is mastered. A 5-month-old does not have the fine motor coordination to use stacking toys.

Which is the best way for parents to aid a toddler in achieving the developmental task?

Allow the toddler to make simple decisions Rationale: The toddler years see a refinement of motor skills, continuous cognitive growth, and the acquisition of language skills. During this time the toddler achieves autonomy and self-control. Allowing the child to make decisions is a good way to help the toddler achieve autonomy and gain independence. Rewarding the child for accomplishing the task after making the decision is a good way to reinforce self-esteem. A younger toddler may not successfully dress alone because he or she may not have mastered such techniques as buttons, zippers, or tying shoes. A toddler can help with household tasks but these are generally limited because the toddler's attention span and motor skills may not be refined enough to complete the task. Helping the child learn to count is improving cognitive development but does not necessarily help the child with gaining autonomy or self-control.

What is the correct amount of wet diapers a mature infant should produce each day?

An infant should have 6 to 8 wet diapers/day. Rationale: 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 nurse is providing education to a teen mother about her 20-month-old daughter's growth. The teen says her daughter seems to have such a big head. What information should the nurse include in the response?

Share that the heads of children at this age are large in proportion to the rest of their body. Rationale: Head circumference increases about 1 inch between 1 and 2 years of age, then increases an average of a half-inch per year until age 5. The anterior fontanel (fontanelle) should be closed by the time the child is 18 months old. Head size becomes more proportional to the rest of the body near the age of 3 years.

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

Sitting Independently Rationale: 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.

When observing a group of toddlers playing in a child care setting, it is noted that the toddlers are all playing with buckets and shovels but are not playing with each other. This type of play is referred to as:

Parallel Play Rationale: The toddler's play moves from the solitary play of the infant to parallel play, in which the toddler plays alongside other children but not with them. Onlooker play is when the child watches others playing but does not engage with them. In associative play toddlers form a group and may even play with the same toy but there is no formal structure of the group.

The nurse is supervising a play group of children on the unit. The nurse expects the toddlers will most likely be involved in which activity?

Playing with the plastic vacuum cleaner and pushing it around the room Rationale: Playtime for the toddler involves imitation of the people around them such as adults, siblings, and other children. Push-pull toys allow them to use their developing gross motor skills. Preschool children have imitative play, pretending to be the mommy, the daddy, a policeman, a cowboy, or other familiar characters. The school-age child enjoys group activities and making things, such as drawings, paintings, and craft projects. The adolescent enjoys activities they can participate in with their peers.

The clinic nurse is assessing a 9-month-old client. The parents state, "Our baby is having a really hard time teething." Which nursing action is appropriate?

Recommend the parents provide the infant a cold teething ring to chew Rationale: Chewing on a cold ring can be very soothing for the tender gumlines during teething. Warm foods offer no relief from teething. Numbing agents are not recommended as they increase the risk of choking. Acetaminophen should not be administered routinely. It may be given every 4 to 6 hours as needed.

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. Rationale: 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.

The father of a toddler reports his son says "no" every time he attempts to correct him. What is the best advice the nurse can offer to the parent?

Saying no is your son's way of trying to exert his independence and is expected. Rationale: It often seems that "no" is a toddler's favorite word. Saying no is his way of beginning to exert his independence. Telling the parent this is a normal happening does not provide the necessary education to the parent. Saying "no" does not indicate the discipline being provided is too restrictive. Telling the father to continue the discipline does not offer the needed education about his child's behavior and stage of development.

Which milestone would the nurse expect an infant to accomplish by 8 months of age?

Sitting without support Rationale: 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 examining a 2-year-old girl for speech and language development. Which finding would suggest a delay in speech development?

The child does not use the names of familiar objects. Rationale: By 24 months most children will name objects familiar to them in their daily lives. Not doing so is strong evidence that a speech delay may exist. Repeating words heard or phrases out of context (echolalia) is normal and a way to practice words and incorporate them in the vocabulary. At 2 years, most children understand much more than they can clearly repeat. Using two-word sentences is a developmental expectation at this age.

In discussing their 2-year-old's behavior with the nurse, which of the parents' statements suggests the child may be ready for toilet teaching?

The child hides behind her bedroom door when defecating. Rationale: Hiding while defecating indicates awareness of this need. Repeating words promotes language development but doesn't indicate readiness for toilet teaching. Walking with a wide, swaying gait is early walking behavior. Steady walking and running signals toileting readiness. Removal of shoes and socks is easily done. Greater fine motor clothing removal skill is needed for toileting.

A nurse is talking to and making facial expressions at a 9-month-old baby girl during a routine office visit. What is the most advanced milestone of language development that the nurse should expect to see in this child?

The infant says "da-da" when looking at her father Rationale: By 9 months, an infant usually speaks a first word: "da-da" or "ba-ba." The other answers refer to earlier milestones in language development. In response to a nodding, smiling face, or a friendly tone of voice, a 3-month-old infant will squeal with pleasure or laugh out loud. By 4 months, infants are very "talkative," cooing, babbling, and gurgling when spoken to. At 6 months, infants learn the art of imitating. They may imitate a parent's cough, for example, or say "Oh!" as a way of attracting attention.

The nurse is performing an assessment on a 8-month-old infant. The infant's medical history notes that he was born at 32 weeks' gestation. The infant is progressing normally. At what adjusted age should the nurse expect the infant's developmental accomplishments?

The infant will most likely present with developmental skills consistent with a 6-month-old infant. Rationale: When assessing the growth and development of a premature infant, the nurse will use the infant's adjusted age to determine expected outcomes. To determine adjusted age, the nurse subtracts the number of weeks that the infant was premature from the infant's chronological age. The infant who was born at 32 weeks' gestation was 8 weeks (or 2 months) premature. To determine the adjusted age, the nurse subtracts 2 months from the chronological age of 8 months: 6 months.

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 Rationale: 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.

The nurse is educating the mother of a newborn about feeding practices. The nurse correctly advises the mother that:

The newborn's stomach can hold between 0.5 oz and 1 oz. Rationale: 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.

When assessing a toddler's language development, what is the standard against which you measure language in a 2-year-old toddler?

The toddler should speak in two-word sentences ("Me go"). Rationale: A toddler can understand language and is able to follow commands far sooner than he or she can actually use the words. By 2 years of age, a toddler typically speaks in two-word (noun and verb) sentences. Two-year-old toddlers have a vocabulary of about 40 to 50 words, and they start to use descriptive words (hungry, hot). The words "ma-ma" and da-da" occur much earlier than the toddler stage. The toddler is about 36 months of age before using pronouns or plurals in sentences. Children are unable to count to 20 until they are 5 to 6 years old.

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 put her to bed when she falls asleep. Rationale: 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 an 6-month-old infant at a well-baby visit and is answering questions from the new mother. Which response should the nurse prioritize when addressing the mother's question concerning what the infant should be learning at this point in life?

Trust Rationale: Erikson identifies various developmental stages which all children accomplish as they grow and develop into adults. The primary psychosocial developmental task for the infant is learning to trust. This task creates the foundation for the developmental tasks of the next stages of the child's life. If the infant does not receive food, love, attention, and comfort, the infant learns to mistrust the environment and those who are responsible for caring for the child. Learning to feel anger, love, and fear come at later times in development.

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. Rationale: 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 examining an 8-month-old girl for appropriate development during a regular check-up. Which observation points to a developmental risk?

Uses only the left hand to grasp Rationale: 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 conducting a support group for parents of 9- and 10-year-olds. The parents express concern about the amount of time their children want to spend with friends outside the home. What should the nurse teach the parents that peer groups provide?

a sense of security as children gain independence Rationale: Nine-year-olds take their peer group seriously. They are more interested in how other children dress than what their parents want them to wear. This is the age where groups are formed and others are excluded from the club. This age group is imitating their peers as they develop their own identity and separate from their parents. Groups are fluid as they change regularly due to many reasons: each member lives on the same street, each member plays on the same ball team, or one member has fewer material things than the others, etc. Security is gained through these clubs because it helps the school-age child develop independence away from the family. Most of the time in the school-age child, peer group relationships are with same-sex friends. Children do not become self-sufficient through these clubs. They remain dependent on their families for their physical needs.