Chapter 05: Health Promotion for the Infant My Nursing Test Banks

Chapter 05: Health Promotion for the Infant

Test Bank

MULTIPLE CHOICE

1. Which milestone is developmentally appropriate for a 2-month-old infant when the nurse pulls the infant to a sitting position?

a.

Head lag is present when the infants trunk is lifted.

b.

The infant is able to support the head when the trunk is lifted.

c.

The infant is briefly able to hold the head erect.

d.

The infant is fully able to support and hold the head in a straight line.

ANS: C

A 2-month-old infant is able to hold the head erect only briefly and continues to have some head lag. It is not until 4 months of age that the infant can keep his or her head in a straight line when pulled to a sitting position.

DIF: Cognitive Level: Application REF: p. 92

OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

2. Approximately what should a newborn weigh at 1 year of age if the newborns birth weight was 7 pounds 6 ounces?

a.

14 3/4 pounds

b.

22 1/8 pounds

c.

29 1/2 pounds

d.

Unable to estimate weight at 1 year

ANS: B

An infant triples the birth weight by 1 year of age. An infant doubles the birth weight by 6 months of age. An infant quadruples the birth weight by 2 years of age. Weight at 6 months, 1 year, and 2 years of age can be estimated from the birth weight.

DIF: Cognitive Level: Application REF: p. 78

OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

3. Which statement made by a parent would be consistent with a developmental delay?

a.

I have noticed that my 9-month-old infant responds consistently to the sound of his name.

b.

I have noticed that my 12-month-old child does not get herself to a sitting position or pull to stand.

c.

I am so happy when my 1 1/2-month-old infant smiles at me.

d.

My 5-month-old infant is not rolling over in both directions yet.

ANS: B

Critical developmental milestones for gross motor development in a 12 month old include standing briefly without support, getting to a sitting position, and pulling to stand. If a 12-month-old child does not perform these activities, it may be indicative of a developmental delay. An infant who responds to his name at 9 months of age is demonstrating abilities to both hear and interpret sound. A social smile is present by 2 months of age. Rolling over in both directions is not a critical milestone for gross motor development until the child reaches 6 months of age.

DIF: Cognitive Level: Analysis REF: p. 103

OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

4. At a healthy 2-month-old infants well-child clinic visit, the nurse should give which immunizations?

a.

DTaP, IPV, HepB, Hib, PCV, rotavirus

b.

MMR, DTaP, PVC, and IPV

c.

Hib, DTaP, rotavirus, and OPV

d.

Hib and MMR, IPV, and rotavirus

ANS: A

DTaP, IPV, HepB, Hib, PCV, and rotavirus are the appropriate sequence of immunizations for a healthy 2-month-old infant. MMR is given at or after 12 months of age. Oral polio vaccine (OPV) is no longer administered in the U.S.

DIF: Cognitive Level: Application REF: p. 92

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

5. The nurse advises the mother of a 3-month-old infant, exclusively breast-fed, to:

a.

start giving the infant a vitamin D supplement.

b.

start using an infant feeder and add rice cereal to the formula.

c.

start feeding the infant rice cereal with a spoon at the evening feeding.

d.

continue breast-feeding without any supplements.

ANS: A

Breast milk does not provide an adequate amount of dietary vitamin D. Infants who are exclusively breast-fed need vitamin D supplements to prevent rickets. An infant feeder is an inappropriate method of providing the infant with caloric intake. Solid foods and rice cereal are not recommended for a 3-month-old infant. Solid feedings do not typically begin before 4 to 6 months of age. Because breast milk is not an adequate source of fluoride, infants need to be given a fluoride supplement.

DIF: Cognitive Level: Comprehension REF: p. 88

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

6. At _____ months of age, an infant should first be expected to locate an object hidden from view.

a.

4

b.

6

c.

9

d.

20

ANS: C

By 9 months of age an infant will actively search for an object that is out of sight. Four-month-old infants are not cognitively capable of searching out objects hidden from their view. Infants at this developmental level do not pursue hidden objects. Six-month-old infants have not developed the ability to perceive objects as permanent and do not search out objects hidden from their view. Twenty-month-old infants actively pursue objects not in their view and are capable of recalling the location of an object not in their view. They first look for hidden objects around the age of 9 months.

DIF: Cognitive Level: Comprehension REF: p. 82

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

7. The parents of a newborn infant state, We will probably not have our baby immunized because we are concerned about the risk of our child being injured. Which is the best response for the nurse to make?

a.

It is your decision.

b.

Have you talked with your parents about this? They can probably help you think about this decision.

c.

The risks of not immunizing your baby are greater than the risks from the immunizations.

d.

You are making a mistake.

ANS: C

Although immunizations have been documented to have a negative effect in a small number of cases, an unimmunized infant is at greater risk for development of complications from childhood diseases than from the vaccines. It is the parents decision not to immunize the child; however, the nurse has a responsibility to inform parents about the risks to infants who are not immunized. Grandparents can be supportive but are not the primary decision makers for the infant. Telling parents that they are making a mistake is an inappropriate response.

DIF: Cognitive Level: Application REF: p. 84

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

8. The mother of a 9-month-old infant is concerned because the infant cries when she leaves him. Which is the best response for the nurse to make to the mother?

a.

You could consider leaving the infant more often so he can adjust.

b.

You might consider taking him to the doctor because he may be ill.

c.

Have you noticed whether the baby is teething?

d.

This can be a healthy sign of attachment.

ANS: D

Healthy attachment is manifested by stranger anxiety in late infancy. An infant who manifests stranger anxiety can be supported by the mother leaving the infant for only short periods of time. Assessing developmental needs is appropriate before taking an infant to a physician. Pain from teething expressed by the infants cries would not occur only when the mother left the room.

DIF: Cognitive Level: Application REF: p. 84

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

9. Which statement concerning physiological factors of infancy is true?

a.

The infant has a slower metabolic rate than an adult.

b.

An infant is not able to digest protein and lactase.

c.

Infants have a slower circulatory response than adults.

d.

The kidneys of an infant are less efficient in concentrating urine than an adults kidneys.

ANS: D

The infants kidneys are not as effective at concentrating urine compared with an adults kidneys because of immaturity of the renal system and a slower glomerular filtration rates. The infants metabolic rate is faster, not slower, than an adults. Although the newborn infants gastrointestinal system is immature, it is capable of digesting protein and lactase, but the ability to digest and absorb fat does not reach adult levels until approximately 6 to 9 months of age.

DIF: Cognitive Level: Comprehension REF: p. 80

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

10. Which is a priority in counseling parents of a 6-month-old infant?

a.

Increased appetite from secondary growth spurt

b.

Allowing the infant to self-feed

c.

Securing a developmentally safe environment for the infant

d.

Strategies to teach infants to sit up

ANS: C

Safety is a primary concern as an infant becomes increasingly mobile. The infants appetite and growth velocity decrease in the second half of infancy. Fine motor development, which is refined in the second half of infancy, is necessary before the infant can self-feed. Unless the infant has a neuromuscular deficit, strategies for teaching a normally developing infant to sit up are not necessary.

DIF: Cognitive Level: Comprehension REF: p. 97

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

11. A mother of a 2-month-old infant tells the nurse, My child doesnt sleep as much as his older brother did at the same age. What is the best response for the nurse?

a.

Have you tried to feed the baby more often?

b.

Infant sleep patterns vary widely, with some infants sleeping only 2 to 3 hours at a time.

c.

It is helpful to keep a record of your babys eating, waking, sleeping, and elimination patterns and to come back in a week to discuss them.

d.

This infant is difficult. It is important for you to identify what is bothering the baby.

ANS: B

Newborn infants may sleep as much as 17 to 20 hours per day. Sleep patterns vary widely, with some infants sleeping only 2 to 3 hours at a time. Infants typically do not need more caloric intake to improve sleep behaviors. Keeping intake, output, waking, and sleeping data is not typically helpful in discussing differences among infants behaviors. Identifying an infant as difficult without identifying helpful actions is not a therapeutic response for a parent concerned about sleep.

DIF: Cognitive Level: Application REF: p. 95

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

12. The mother of a 10-month-old infant tells the nurse that her infant really likes cows milk. Which is the best response to this mother?

a.

Milk is good for him.

b.

It is best to wait until he is a year old before giving him cows milk.

c.

Limit cows milk to his bedtime bottle.

d.

Mix his cereal with cows milk and give him formula in a bottle.

ANS: B

It is best to wait until the infant is at least a year old before giving him cows milk because of the risk of allergies and intestinal problems. Cows milk protein intolerance is the most common food allergy during infancy. Although milk is a good source of calcium and protein for children after the first year of life, it is not the best source of nutrients for children younger than 1 year old. Bedtime bottles of formula or milk are contraindicated because of their high sugar content, which leads to dental decay in primary teeth. Cereal can be mixed with formula.

DIF: Cognitive Level: Application REF: p. 90

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

13. The mother of a 10-month-old infant asks the nurse about beginning to wean her child from the bottle. Which statement by the mother suggests that the child is not ready to be weaned?

a.

My son is frequently throwing his bottle down.

b.

The baby takes a few ounces of formula from the bottle.

c.

He is constantly chewing on the nipple. It concerns me.

d.

He consistently is sucking.

ANS: D

Consistent sucking is a sign that the child is not ready to be weaned. A decreased interest in the bottle starts between 6 and 12 months. Throwing the bottle down is a sign of a decreased interest in the bottle. When the child is taking more fluids from a cup and decreasing amounts from the bottle, the child is demonstrating a readiness for weaning. Chewing on the nipple is another sign that the infant is ready to be weaned.

DIF: Cognitive Level: Analysis REF: p. 91

OBJ: Nursing Process Step: Evaluation MSC: Health Promotion and Maintenance

14. Which is appropriate play for a 6-month-old infant?

a.

Pat-a-cake, peek-a-boo

b.

Ball rolling, hide and seek game

c.

Bright rattles and tactile toys

d.

Push and pull toys

ANS: A

Six-month-old children enjoy playing pat-a-cake and peek-a-boo. Nine-month-old infants enjoy rolling a ball and playing hide and seek games. Four-month-old infants enjoy bright rattles and tactile toys. Twelve-month-old infants enjoy playing with push and pull toys.

DIF: Cognitive Level: Comprehension REF: p. 96

OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

15. Which statement by a mother indicates that her 5-month-old infant is ready for solid food?

a.

When I give my baby solid foods, she has difficulty getting it to the back of her throat to swallow.

b.

She has just started to sit up without any support.

c.

I am surprised that she only weighs 11 pounds. I expected her to have gained some weight.

d.

I find that she really has to be encouraged to eat.

ANS: B

Sitting is a sign that the child is ready to begin with solid foods. Children who are ready to manage solid foods are able to move food to the back of their throats to swallow. Infants who weigh less than 13 pounds and demonstrate a lack of interest in eating are not ready to be started on solid foods. Infants who are difficult feeders and do not demonstrate an interest in solid foods are not ready to be started on them.

DIF: Cognitive Level: Analysis REF: p. 93

OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

16. A mother asks the nurse, When should I begin to clean my babys teeth? What is the best response for the nurse?

a.

You can begin when all her baby teeth are in.

b.

You can easily begin now. Just put some toothpaste on a gauze pad to clean the teeth.

c.

I dont think you have to worry about that until she can handle a toothbrush.

d.

You can begin as soon as your child has a tooth. The easiest way is to take cotton swabs or a face cloth and just wipe the teeth. Toothpaste is not necessary.

ANS: D

An infants teeth need to be cleaned as soon as they erupt. Cleaning the teeth with cotton swabs or a face cloth is appropriate. Waiting until all the baby teeth are in is inappropriate and prolongs cleaning until 2 years of age. Because toothpaste contains fluoride and infants will swallow the toothpaste, parents should avoid its use. Even when a child has the ability to hold a toothbrush, the parent should continue cleaning the childs teeth.

DIF: Cognitive Level: Comprehension REF: p. 95

OBJ: Nursing Process Step: Planning MSC: Physiological Integrity

MULTIPLE RESPONSE

1. A nurse has completed a teaching session for parents about baby-proofing the home. Which statements made by the parents indicate an understanding of the teaching? Select all that apply.

a.

We will put plastic fillers in all electrical plugs.

b.

We will place poisonous substances in a high cupboard.

c.

We will place a gate at the top and bottom of stairways.

d.

We will keep our household hot water heater at 130 degrees.

e.

We will remove front knobs from the stove.

ANS: A, C, E

By the time babies reach 6 months of age, they begin to become much more active, curious, and mobile. Putting plastic fillers on all electrical plugs can prevent an electrical shock. Putting gates at the top and bottom of stairways will prevent falls. Removing front knobs form the stove can prevent burns. Poisonous substances should be stored in a locked cabinet not in a cabinet that children can reach when they begin to climb. The household hot water heater should be turned down to 120 degrees or less.

DIF: Cognitive Level: Analysis REF: p. 78

OBJ: Nursing Process Step: Evaluation MSC: Health Promotion and Maintenance

SHORT ANSWER

1. An infants length was 20 inches at birth. What should the nurse expect the infants length to be at 6 months (in inches)?

ANS:

26

During the first 6 months, infants increase their birth length by approximately 1 inch (2.54 cm) per month, slowing to 1/2 inch (1.27 cm) per month over the next 6 months.

DIF: Cognitive Level: Analysis REF: p. 81

OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

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