Chapter 31 - the infant and family (evolve)
The nurse is assessing a 4-month-old infant. Which reflex should the nurse expect to find in the infant? Rooting Crawling Drooling Tonic neck
drooling
The nurse is assessing a 6-month-old infant who smiles, coos, and has a strong head lag. What should the nurse recognize is true? This assessment is normal. The child is probably cognitively impaired. A developmental/neurologic evaluation is needed. The parent needs to work with the infant to stop head lag.
A developmental/neurologic evaluation is needed.
Which characteristic of fine motor skills does the nurse expect to find in a 5-month-old infant? Neat pincer grasp Strong grasp reflex Able to grasp object voluntarily Able to build a tower of two cubes
Able to grasp object voluntarily
Which symptoms does the nurse expect to find in the teething infant? Irritability Drooling Vomiting Skin rashes Facial edema
Irritability Drooling
A 4-month-old infant is scheduled for heart surgery. Which nursing action is most appropriate to follow 2 hours before the surgery? Give a doll to the infant to play with Place a pacifier in the infant's mouth to suck Give a toy cell phone to the infant to play with Place a bottle of milk in the infant's mouth to suck
Place a pacifier in the infant's mouth to suck
Which developmental changes are observed in a 5-month-old infant? Birth weight has doubled. The rooting reflex is present. There are signs of tooth eruption. Head and chest circumference are equal. Length has increased by 50% from length at birth.
Birth weight has doubled. There are signs of tooth eruption.
The most appropriate recommendation for relief of teething pain is to instruct the parents to do what? Rub gums with aspirin to relieve inflammation Apply hydrogen peroxide to gums to relieve irritation Give child a cold teething ring to relieve inflammation Have child chew on a warm teething ring to encourage tooth eruption
Give child a cold teething ring to relieve inflammation
A parent asks the nurse in the well-baby clinic, "Which toy should be given to the 3-month-old infant?" Which toy does the nurse suggest to the infant's parent? Push-pull toy Soft stuffed toy Play telephone Large plastic ball
Soft stuffed toy
A 6-month-old infant's parent asks the nurse, "What is the best alternative to breastfeeding?" What appropriate response should the nurse give to the infant's parents? "Skim milk is an alternative to breastfeeding." "Imitation milk is an alternative to breastfeeding." "Commercial iron-fortified formula is an alternative." "Pasteurized whole cow's milk is acceptable to give."
"Commercial iron-fortified formula is an alternative."
The nurse is educating a group of mothers about injury prevention for infants. Which statements by the nurse indicate effective teaching? "Diaper pins should be kept away from the child." "The floor should be clean where the child crawls." "A smoke detector should be installed in the home." "Heat the Infant formula before giving it to the infant." "Pour hot liquids in a cup with the child sitting on your lap."
"Diaper pins should be kept away from the child." "The floor should be clean where the child crawls." "A smoke detector should be installed in the home."
Which fine motor activity is likely to be observed in a 7-month-old infant? Searching for a toy that was hidden Attempting to build a two-block tower Putting objects one at a time in a box Transferring objects between both hands
Transferring objects between both hands
The nurse is assessing a 9-month-old infant. Which type of play should the nurse suggest to the infant's parents? Peekaboo Pat-a-cake Push-pull toy Soft stuffed toy Large plastic ball
Peekaboo Pat-a-cake
The nurse is assessing a 5-month-old infant. Which behavior does the nurse observe in the infant? Taking out objects hidden under a pillow Transferring toys from one hand to the other Picking up a toy and putting it into the mouth Grasping the feet and pulling them toward mouth
Picking up a toy and putting it into the mouth
Which fine motor activity can be observed in a 4-month-old infant? Holding a bottle Grasping objects Playing with a rattle Taking objects directly to mouth
Playing with a rattle
While assessing an infant, the nurse notices a typical bald spot, a symmetric distortion of the skull, and torticollis. What should the nurse interpret from this assessment? The infant has a bacterial infection. The infant has a vitamin E deficiency. The infant has a vitamin C deficiency. The infant has positional plagiocephaly.
The infant has positional plagiocephaly.
The mother of a 3-month-old breastfed infant asks about giving her baby water because it is summer and very warm. What should the nurse recommend? Fluids in addition to breast milk are not needed. Clear juices would be better than water to promote adequate fluid intake. Water should be given if the infant seems to breastfeed longer than usual. Water once or twice a day will make up for losses caused by environmental temperature.
Fluids in addition to breast milk are not needed.
The nurse assesses that the infant has difficulty breathing, decreased heart rate, change in skin color, and an ill-looking appearance. What should be the first nursing intervention in this situation? Alternate the infant's head position Place the infant in the prone position Place the infant in side-lying position Rub the trunk gently to wake the child
Rub the trunk gently to wake the child
The parents of a 9-month-old infant tell the nurse that they are worried about their baby's thumb-sucking. What is the nurse's best reply? A pacifier should be substituted for the thumb. Thumb-sucking should be discouraged by age 12 months. There is no need to restrain nonnutritive sucking during infancy. Thumb-sucking should be discouraged when the teeth begin to erupt.
There is no need to restrain nonnutritive sucking during infancy.
The nurse is teaching nursing students about vaccine administration. Which statement made by the nursing student indicates effective learning? "Vapocoolant spray should apply to the skin after administering the vaccine." "The influenza vaccine should not be administered to the patient with asthma." "All vaccines should be given to adults by using a 25-mm (1-in) length needle." "A 16-mm (5/8-inch) length needle is used to administer the vaccine to newborns."
"A 16-mm (5/8-inch) length needle is used to administer the vaccine to newborns."
A 3-month-old bottle-fed infant is allergic to cow's milk. What is the nurse's best option for a substitute? Goat's milk Soy-based formula Skim milk diluted with water Casein hydrolysate milk formula
Casein hydrolysate milk formula
Which normal findings (age and developmentally appropriate) does the nurse find during the assessment of a 5-month-old child? . Startle reflex Tooth eruption Babinski reflex Tonic neck reflex Doubling of birth weight
Tooth eruption Babinski reflex Doubling of birth weight
The nurse is caring for an infant who has an iron deficiency. The primary health care provider (PHP) has prescribed oral iron supplements to the infant. What instruction should the nurse give to the infant's parents for the safe administration of the supplement? Administer the medication mixed with fluids Administer the medication with all the meals Administer the medication in between meals Administer the medication with milk products
Administer the medication in between meals
A parent of an 8-month-old infant tells the nurse that the baby cries and screams whenever he or she is left with the grandparents. The nurse's reply should be based on knowledge that what is true? The infant is most likely spoiled. This is a normal reaction for this age. This is an abnormal reaction for this age. The grandparents are not responsive to that infant.
This is a normal reaction for this age.
The nurse is assessing a 12-month-old child during a well-child visit. The nurse notices that the child's birth weight has tripled, birth length is increased by 50%, head and chest circumference are equal, and the child has six deciduous teeth. What does the nurse conclude that the child has from these findings? A calcium deficiency Normal development Delayed development Excessive weight gain
normal development
The parent of a 12-month-old infant says to the nurse, "He pushes the teaspoon right out of my hand when I feed him. I can't let him feed himself; he makes too much of a mess." What is the nurse's best response? "It's important to let him make a mess. Just try not to worry about it so much." "It's important not to give in to this kind of temper tantrum at this age. Simply ignore the behavior and the mess." "You need to try different types of utensils, bowls, and plates. Some are specifically designed for young children." "Feeding himself will help foster his growth and development. Perhaps we can discuss ways to make the messes more tolerable."
"Feeding himself will help foster his growth and development. Perhaps we can discuss ways to make the messes more tolerable."
Which activity does the nurse expect to observe in a 4-month-old infant? The infant grasps an object by using both hands. The infant grabs an object by pulling on a string. The infant transfers objects between both hands. The infant matches two cubes and brings them together.
The infant grasps an object by using both hands.
The primary health care provider (PHP) prescribed HepB (Recombivax HB) vaccine for a child. Which question should the nurse ask the child's parents to ensure it is safe to administer the vaccine? "Does your child have a history of respiratory tract infection?" "Does your child have a history of any urinary tract infections?" "Does your child have a history of being hypersensitive to yeast?" "Does your child have a history of skin infections such as impetigo?"
"Does your child have a history of being hypersensitive to yeast?"
The nurse is educating a group of parents about safety promotion and injury prevention in the infant. Which statement made by a parent indicates effective teaching? "The mattresses in the house should be covered with plastic." "It is okay to give the child colored latex balloons at playtime." "Diaper pins should be kept closed and away from the infant." "Infant formula should be microwaved before feeding the child."
"Diaper pins should be kept closed and away from the infant."
The parents of a 7-month-old infant report to the nurse that the solid food they feed to the baby passes through the gastrointestinal tract unchanged. Which response of the nurse would help to relieve the parent's anxiety? "It is a normal finding at this age." "It indicates an intestinal infection." "The infant has slow development." "The infant has a metabolic disorder."
"It is a normal finding at this age."
The nurse is educating a group of mothers about expressing breast milk for feeding the infant. Which statement made by the parents indicates the need for further teaching? "The expressed breast milk should be stored in an airtight glass container in the fridge." "The expressed breast milk should be frozen (-18° C [0° F]) safely for up to 6 months." "The expressed breast milk should be stored in the refrigerator (4° C [39° F]) up to 5 days." "The expressed breast milk should be heated in a microwave before feeding my baby."
"The expressed breast milk should be heated in a microwave before feeding my baby."
A 4-month-old infant is brought to the clinic by his parents for a well-baby checkup. What should the nurse include at this time concerning injury prevention? "Keep doors of appliances closed at all times." "Never shake baby powder directly on your infant because it can be aspirated into his lungs." "Do not permit your child to chew paint from window ledges because he might absorb too much lead." "When your baby learns to roll over, you must supervise him whenever he is on a surface from which he might fall."
"When your baby learns to roll over, you must supervise him whenever he is on a surface from which he might fall."
As the nurse is assessing an infant, the nurse notices that the teeth are erupting and the infant's skin color is bluish. After assessing oxygenation, the nurse reviews the laboratory report and finds that the infant has methemoglobinemia. What would be the probable reason for this? Application of topical anesthetics Excessive use of cold teething ring Administration of aspirin (Acuprine) Excessive consumption of hard candy
Application of topical anesthetics
A mother observes that her 7-month-old infant bears full weight on the feet when held in a standing position. What is the reason for this? It indicates that the child will start walking within 2 months. It indicates that the child's growth and development is normal. It indicates that infant physical development is occurring slowly. It reflects that the infant's upper limbs are not developing properly.
It indicates that the child's growth and development is normal.
Which strategy might be recommended for an infant with failure-to-thrive to increase caloric intake? Avoiding solids until after the bottle is well accepted Varying schedule of routine activities on a daily basis Being persistent through 10 to 15 minutes of food refusal Using developmental stimulation by a specialist during feedings
Being persistent through 10 to 15 minutes of food refusal
Cooper is an 8-year-old who is very excited about attending Lacrosse camp this summer. His mother has received registration forms along with a request for a physical examination and recommendations to have all immunizations up to date. The nurse is preparing the examination room for Cooper's visit and is responsible for administering the necessary boosters. Using the chart below, determine which catch-up doses Cooper will need. He is not considered high risk. Hib DTaP MMR Varicella Rotavirus Hepatitis B
DTaP MMR Varicella Hepatitis B
Which activity of a 10-month-old infant indicates the development of object permanence? Looking for a hidden object that the infant had seen earlier Transferring the objects from the right hand to the left hand Grasping the foot and pulling it to the mouth to suck the toe Picking up a toy from the ground and putting it in the mouth
Looking for a hidden object that the infant had seen earlier
The health care provider has prescribed a liquid iron supplement for an infant with iron deficiency. What advice does the nurse give to the parents to prevent the infant's teeth from staining from the liquid iron supplement? Use a supplement with a low iron content Mix the iron with any kind of citrus fruit juice Use a dropper toward the back of the mouth Dilute with whole cow's milk or milk products
Use a dropper toward the back of the mouth
A mother is bringing her 4-month-old infant into the clinic for a routine well-baby check. The mother is breastfeeding exclusively. There are no other liquids given to the infant. What vitamin does the nurse anticipate the provider will prescribe for this infant? Vitamin B Vitamin D Vitamin C Vitamin K
Vitamin D
The nurse is caring for a 2-month-old infant with the flu. The infant is crying due to colicky pain. The nurse tries to soothe the infant, but the infant continues to cry. What does the nurse do in this situation? Offer milk products to the infant Offer the infant a bottle of diluted juice Change the diaper before returning the infant to the crib Walk with the infant's face down and with the body across a parent's arm
Walk with the infant's face down and with the body across a parent's arm
The nurse educator instructs a nursing student that according to Erikson, infancy is concerned with acquiring a sense of what? Trust Industry Initiative Separation
trust
The nurse advises the parents of a 2-year-old child to vaccinate their child with the influenza vaccine (inactivated influenza vaccine [IIV]). The child's parents ask the nurse, "My child had the same vaccine last year. Why does my child need another one?" Which response should the nurse give to the child's parent? "All children require influenza booster shots every year up to 12 years of age." "Different strains of influenza are used to manufacture the vaccine each year." "The effectiveness of the influenza vaccine decreases 6 months after the dose." "The child needs to receive the influenza vaccine early due to lack of immunity."
"Different strains of influenza are used to manufacture the vaccine each year."
The nurse is educating parents about sudden infant death syndrome (SIDS). What instructions should the nurse give to the parents for preventing SIDS? "The side-lying position is the best for the infant." "Smoking should be prohibited around the infant." "Adults should not share their bed with the infant." "Soft bedding should be used for the infant's bed." "Preterm infants can be placed in the supine position."
"Smoking should be prohibited around the infant." "Adults should not share their bed with the infant." "Preterm infants can be placed in the supine position."
The nurse should provide further teaching about sudden infant death syndrome (SIDS) prevention when hearing the mother of an 8-week-old make which statement? "I only smoke in the kitchen." "I put my baby to sleep on her back." "I have my baby sleep with me instead of alone in the crib." "I make sure my baby wears a flannel sleeper and has two blankets to keep warm in her crib." "I always leave my baby's favorite stuffed bunny rabbit in the crib to keep her from crying at night."
"I only smoke in the kitchen." "I have my baby sleep with me instead of alone in the crib." "I make sure my baby wears a flannel sleeper and has two blankets to keep warm in her crib." "I always leave my baby's favorite stuffed bunny rabbit in the crib to keep her from crying at night."
During a home visit, the parents report to the nurse that they are worried about their 3-year-old child's behavior. The child lacks discipline and writes on the walls. Which nursing advice would be helpful for the parents for limiting the child's behavior? "Send the child to his or her bedroom for a time-out." "Instruct the child to stand in play yard for some time." "Seclude the child in the store room for a punishment." "Scold the child in a firm, loud tone for the misbehavior."
"Instruct the child to stand in play yard for some time."
What are the primary goals in the nutritional management of children with failure to thrive (FTT)? Allow for catch-up growth Correct nutritional deficiencies Achieve ideal weight for height Restore optimum body composition Educate the parents or primary caregivers on child's nutritional requirements Educate the parents or primary caregivers that the child will need tube feedings first
Allow for catch-up growth Correct nutritional deficiencies Achieve ideal weight for height Restore optimum body composition Educate the parents or primary caregivers on child's nutritional requirements
Which activities are indicative of the teething process in an infant? Increased need for sleep Infant rubbing on the gums Infant biting on hard objects Eating a lot more solid foods Increased sucking on fingers
Infant rubbing on the gums Infant biting on hard objects Increased sucking on fingers
An 8-month-old infant is able to pick up pieces of food. The parent is impressed with this skill and tells the nurse about it. What does the nurse tell to the infant's parent about this behavior? It indicates that the infant is hyperactive. It is pincer grasp, which is expected at this age. It is palmar grasp, which is expected at this age. It is an abnormal finding that requires evaluation.
It is pincer grasp, which is expected at this age.
During the assessment of a 12-month-old infant, the nurse finds that the infant's head and chest circumference are equal, the length of the infant has increased by 50% since birth, and the weight is triple that of the birth weight. What does the nurse interpret from these findings? The infant has slow development. The infant has normal development. The infant has inadequate weight gain. The infant has insufficient dietary protein.
The infant has normal development.
Apnea of infancy has been diagnosed in an infant who will soon be discharged with home monitoring. When teaching the parents about the infant's care, what is the most important information the nurse should include in the discharge teaching plan? Cardiopulmonary resuscitation (CPR) Administration of intravenous (IV) fluids Reassurance that the infant cannot be electrocuted during monitoring Advice that the infant not be left with other caretakers such as baby-sitters
Cardiopulmonary resuscitation (CPR)
The nurse is providing education to a parent of a 10-month-old infant receiving iron supplements. What will be included in the teaching? Administer iron with meals Mix iron with milk for greater absorption Report black, tarry stools to health care provider Place iron toward the back side of the mouth with a dropper Caution parents not to switch to a low-iron-containing formula or milk
Place iron toward the back side of the mouth with a dropper Caution parents not to switch to a low-iron-containing formula or milk
The exhausted parents of a 2-month-old infant with colic ask the nurse what is the best method to promote comfort and sleep for the infant. What is the nurse's initial action? Take a thorough, detailed history of usual daily events Advise the mother to follow a milk-free diet for 3 to 5 days Administer simethicone drops to provide relief from gas pains Explain that the parents need to stay calm so the infant will remain calm
Take a thorough, detailed history of usual daily events
The nursing student asks the senior nurse, "Which are the suitable play items for an 8-month-old infant?" Which suitable play items does the nurse suggest to the nursing student? Textured book Modeling clay Stuffed animal Play telephone Hanging mobile
Textured book Stuffed animal Hanging mobile
The parents of a 6-month-old infant report to the nurse that the infant is not sleeping properly and is refusing to eat solid foods. The infant is also biting on hard objects and sucking his fingers continuously. What should the nurse interpret from these symptoms? The child has digestion problem. The child shows signs of teething. The child has a bacterial infection. The child has a vitamin D deficiency.
The child shows signs of teething.
Which fine motor activity does the nurse observe in a 6-month-old infant? The infant can hold a milk bottle. The infant drops a cube in the cup. The infant is able to hold two cubes. The infant grabs a bell by the handle.
The infant can hold a milk bottle.