Chapter 10: Health Promotion of the Infant and Family My Nursing Test Banks

Chapter 10: Health Promotion of the Infant and Family

MULTIPLE CHOICE

1. At which age does an infant start to recognize familiar faces and objects, such as his or her own hand?

a.

1 month

b.

2 months

c.

3 months

d.

4 months

ANS: C

The child can recognize familiar objects at approximately age 3 months. For the first 2 months of life, infants watch and observe their surroundings. The 4-month-old infant is beginning to develop handeye coordination.

DIF: Cognitive Level: Understanding REF: p. 422

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

2. During the 2-month well-child checkup, the nurse expects the infant to respond to sound in which manner?

a.

Respond to name.

b.

React to loud noise with Moro reflex.

c.

Turn his or her head to side when sound is at ear level.

d.

Locate sound by turning his or her head in a curving arc.

ANS: C

At 2 months of age, an infant should turn his or her head to the side when a noise is made at ear level. At birth, infants respond to sound with a startle or Moro reflex. An infant responds to his or her name and locates sounds by turning his or her head in a curving arc at age 6 to 9 months.

DIF: Cognitive Level: Understanding REF: p. 430

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

3. Which characteristic best describes the fine motor skills of an infant at age 5 months?

a.

Neat pincer grasp

b.

Strong grasp reflex

c.

Builds a tower of two cubes

d.

Able to grasp object voluntarily

ANS: D

At age 5 months, the infant should be able to voluntarily grasp an object. The grasp reflex is present in the first 2 to 3 months of life. Gradually, the reflex becomes voluntary. The neat pincer grasp is not achieved until age 11 months. At age 12 months, an infant will attempt to build a tower of two cubes but will most likely be unsuccessful.

DIF: Cognitive Level: Understanding REF: p. 430

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

4. The nurse is checking reflexes on a 7-month-old infant. When the infant is suspended in a horizontal prone position, the head is raised and the legs and spine are extended. Which reflex is this?

a.

Landau

b.

Parachute

c.

Body righting

d.

Labyrinth righting

ANS: A

When the infant is suspended in a horizontal prone position, the head is raised and the legs and spine are extended; this describes the Landau reflex. It appears at 6 to 8 months and persists until 12 to 24 months. The parachute reflex occurs when the infant is suspended in a horizontal prone position and suddenly thrust downward; the infant extends the hands and fingers forward as if to protect against falling. This appears at age 7 to 9 months and lasts indefinitely. Body righting occurs when turning the hips and shoulders to one side causes all other body parts to follow. It appears at 6 months of age and persists until 24 to 36 months. The labyrinth-righting reflex appears at 2 months and is strongest at 10 months. This reflex involves holding infants in the prone or supine position. They are able to raise their heads.

DIF: Cognitive Level: Applying REF: p. 433

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

5. In terms of gross motor development, what should the nurse expect an infant age 5 months to do?

a.

Sit erect without support.

b.

Roll from the back to the abdomen.

c.

Turn from the abdomen to the back.

d.

Move from a prone to a sitting position.

ANS: C

Rolling from the abdomen to the back is developmentally appropriate for a 5-month-old infant. The ability to roll from the back to the abdomen is developmentally appropriate for an infant at age 6 months. Sitting erect without support is a developmental milestone usually achieved by 8 months. A 10-month-old infant can usually move from a prone to a sitting position.

DIF: Cognitive Level: Understanding REF: p. 431

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

6. At which age can most infants sit steadily unsupported?

a.

4 months

b.

6 months

c.

8 months

d.

12 months

ANS: C

Sitting erect without support is a developmental milestone usually achieved by 8 months. At age 4 months, an infant can sit with support. At age 6 months, the infant will maintain a sitting position if propped. By 10 months, the infant can maneuver from a prone to a sitting position.

DIF: Cognitive Level: Understanding REF: p. 419

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

7. By which age should the nurse expect that an infant will be able to pull to a standing position?

a.

5 to 6 months

b.

7 to 8 months

c.

11 to 12 months

d.

14 to 15 months

ANS: C

Most infants can pull themselves to a standing position at age 9 months. Infants who are not able to pull themselves to standing by age 11 to 12 months should be further evaluated for developmental dysplasia of the hip. At 6 months, infants have just obtained coordination of arms and legs. By age 8 months, infants can bear full weight on their legs.

DIF: Cognitive Level: Understanding REF: p. 419

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

8. According to Piaget, a 6-month-old infant should be in which developmental stage?

a.

Use of reflexes

b.

Primary circular reactions

c.

Secondary circular reactions

d.

Coordination of secondary schemata

ANS: C

Infants are usually in the secondary circular reaction stage from ages 4 to 8 months. This stage is characterized by a continuation of the primary circular reaction for the response that results. Shaking is performed to hear the noise of the rattle, not just for shaking. The use of reflexes stage is primarily during the first month of life. The primary circular reaction stage marks the replacement of reflexes with voluntary acts. The infant is in this stage from ages 1 to 4 months. The fourth sensorimotor stage is coordination of secondary schemata, which occurs at ages 9 to 12 months. This is a transitional stage in which increasing motor skills enable greater exploration of the environment.

DIF: Cognitive Level: Understanding REF: p. 422

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

9. At which age do most infants begin to fear strangers?

a.

2 months

b.

4 months

c.

6 months

d.

12 months

ANS: C

Between ages 6 and 8 months, fear of strangers and stranger anxiety become prominent and are related to infants ability to discriminate between familiar and unfamiliar people. At 2 months, infants are just beginning to respond differentially to their mothers. The infant at age 4 months is beginning the process of separation-individuation, which involves recognizing the self and mother as separate beings. Twelve months is too late; the infant requires referral for evaluation if he or she does not fear strangers by this age.

DIF: Cognitive Level: Understanding REF: p. 426

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

10. At which age should the nurse expect most infants to begin to say mama and dada with meaning?

a.

4 months

b.

6 months

c.

10 months

d.

14 months

ANS: C

Beginning at about age 10 months, an infant is able to ascribe meaning to the words mama and dada. Four to 6 months is too young for this behavior to develop. At 14 months, the child should be able to attach meaning to these words. By age 1 year, the child can say three to five words with meaning and understand as many as 100 words.

DIF: Cognitive Level: Understanding REF: p. 426

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

11. At which age should the nurse expect an infant to begin smiling in response to pleasurable stimuli?

a.

1 month

b.

2 months

c.

3 months

d.

4 months

ANS: B

At age 2 months, the infant has a social, responsive smile. A reflex smile is usually present at age 1 month. A 3-month-old infant can recognize familiar faces. At age 4 months, infants can enjoy social interactions.

DIF: Cognitive Level: Understanding REF: p. 427

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

12. The nurse is discussing development and play activities with the parent of a 2-month-old boy. Which statement by the parent would indicate a correct understanding of the teaching?

a.

I can give my baby a ball of yarn to pull apart or different textured fabrics to feel.

b.

I can use a music box and soft mobiles as appropriate play activities for my baby.

c.

I should introduce a cup and spoon or pushpull toys for my baby at this age.

d.

I do not have to worry about appropriate play activities at this age.

ANS: B

Music boxes and soft mobiles are appropriate play activities for a 2-month-old infant. A ball of yarn to pull apart or different textured fabrics are appropriate for an infant at 6 to 9 months. A cup and spoon or pushpull toys are appropriate for an older infant. Infants of all ages should be exposed to appropriate types of stimulation.

DIF: Cognitive Level: Analyzing REF: p. 428

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

13. What is an appropriate play activity for a 7-month-old infant to encourage visual stimulation?

a.

Playing peek-a-boo

b.

Playing pat-a-cake

c.

Imitating animal sounds

d.

Showing how to clap hands

ANS: A

Because object permanence is a new achievement, peek-a-boo is an excellent activity to practice this new skill for visual stimulation. Playing pat-a-cake and showing how to clap hands help with kinetic stimulation. Imitating animal sounds helps with auditory stimulation.

DIF: Cognitive Level: Applying REF: p. 428 TOP: Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance

14. What information should be given to the parents of a 12-month-old child regarding appropriate play activities for this age?

a.

Give large pushpull toys for kinetic stimulation.

b.

Place a cradle gym across the crib to help develop fine motor skills.

c.

Provide the child with finger paints to enhance fine motor skills.

d.

Provide a stick horse to develop gross motor coordination.

ANS: A

A 12-month-old child is able to pull to a stand and walk holding on or independently. Appropriate toys for this age child include large pushpull toys for kinetic stimulation. A cradle gym should not be placed across the crib. Finger paints are appropriate for older children. A 12-month-old child does not have the stability to use a stick horse.

DIF: Cognitive Level: Applying REF: p. 428

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

15. The parents of a 2-month-old boy are concerned about spoiling their son by picking him up when he cries. What is the nurses best response?

a.

Allow him to cry for no longer than 15 minutes and then pick him up.

b.

Babies need comforting and cuddling. Meeting these needs will not spoil him.

c.

Babies this young cry when they are hungry. Try feeding him when he cries.

d.

If he isnt soiled or wet, leave him, and hell cry himself to sleep.

ANS: B

Parents need to learn that a spoiled child is a response to inconsistent discipline and limit setting. It is important to meet the infants developmental needs, including comforting and cuddling. The data suggest that responding to a childs crying can actually decrease the overall crying time. Allowing him to cry for no longer than 15 minutes and then picking him up will reinforce prolonged crying. Infants at this age have other needs besides feeding. The parents should be taught to identify their infants cues. Counseling parents on letting the baby cry himself to sleep when not soiled or wet refers to sleep issues, not general infant behavior.

DIF: Cognitive Level: Applying REF: p. 429

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

16. The nurse is interviewing the father of a 10-month-old girl. The child is playing on the floor when she notices an electrical outlet and reaches up to touch it. Her father says no firmly and moves her away from the outlet. The nurse should use this opportunity to teach the father what?

a.

That the child should be given a time-out

b.

That the child is old enough to understand the word no

c.

That the child will learn safety issues better if she is spanked

d.

That the child should already know that electrical outlets are dangerous

ANS: B

By age 10 months, children are able to associate meaning with words. The father is using both verbal and physical cues to alert the child to dangerous situations. A time-out is not appropriate. The child is just learning about the environment. Physical discipline should be avoided. The 10-month-old child is too young to understand the purpose of an electrical outlet.

DIF: Cognitive Level: Applying REF: p. 426

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

17. At a well-child visit, parents ask the nurse how to know if a daycare facility is a good choice for their infant. Which observation should the nurse stress as especially important to consider when making the selection?

a.

Developmentally appropriate toys

b.

Nutritious snacks served to the children

c.

Handwashing by providers after diaper changes

d.

Certified caregivers for each of the age groups at the facility

ANS: C

Health practices should be most important. With the need for diaper changes and assistance with feeding, young children are at increased risk when handwashing and other hygienic measures are not consistently used. Developmentally appropriate toys are important, but hygiene and the prevention of disease transmission take precedence. An infant should not have snacks. This is a concern for an older child. Certified caregivers for each age group may be an indicator of a high-quality facility, but parental observation of good hygiene is a better predictor of care.

DIF: Cognitive Level: Applying REF: p. 435

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Safe and Effective Care Environment

18. A breastfed infant is being seen in the clinic for a 6-month checkup. The mother tells the nurse that the infant recently began to suck her thumb. Which is the best nursing intervention?

a.

Reassure the mother that this is normal at this age.

b.

Recommend the mother substitute a pacifier for her thumb.

c.

Assess the infant for other signs of sensory deprivation.

d.

Suggest the mother breastfeed the infant more often to satisfy her sucking needs.

ANS: A

Sucking is an infants chief pleasure, and the infant may not be satisfied by bottle-feeding or breastfeeding alone. During infancy and early childhood, there is no need to restrict nonnutritive sucking. The nurse should explore with the mother her feelings about a pacifier versus the thumb. No data support that the child has sensory deprivation.

DIF: Cognitive Level: Applying REF: p. 436

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

19. An infant, age 6 months, has six teeth. The nurse should recognize that this is what?

a.

Normal tooth eruption

b.

Delayed tooth eruption

c.

Unusual and dangerous

d.

Earlier than expected tooth eruption

ANS: D

Six months is earlier than expected to have six teeth. At age 6 months, most infants have two teeth. Although unusual, having six teeth at 6 months is not dangerous.

DIF: Cognitive Level: Understanding REF: p. 437

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

20. Which intervention is the most appropriate recommendation for relief of teething pain?

a.

Rub gums with aspirin to relieve inflammation.

b.

Apply hydrogen peroxide to gums to relieve irritation.

c.

Give the infant a frozen teething ring to relieve inflammation.

d.

Have the infant chew on a warm teething ring to encourage tooth eruption.

ANS: C

Teething pain is a result of inflammation, and cold is soothing. A frozen teething ring or ice cube wrapped in a washcloth helps relieve the inflammation. Aspirin is contraindicated secondary to the risks of aspiration. Hydrogen peroxide does not have an anti-inflammatory effect. Warmth increases inflammation.

DIF: Cognitive Level: Applying REF: p. 437

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

21. 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 tell her?

a.

Fluids in addition to breast milk are not needed.

b.

Water should be given if the infant seems to nurse longer than usual.

c.

Clear juices are better than water to promote adequate fluid intake.

d.

Water once or twice a day will make up for losses resulting from environmental temperature.

ANS: A

Infants who are breastfed or bottle fed do not need additional water during the first 4 months of life. Excessive intake of water can create problems such as water intoxication, hyponatremia, or failure to thrive. Juices provide empty calories for infants.

DIF: Cognitive Level: Applying REF: p. 438

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

22. At what age is it safe to give infants whole milk instead of commercial infant formula?

a.

6 months

b.

9 months

c.

12 months

d.

18 months

ANS: C

The American Academy of Pediatrics does not recommend the use of cows milk for children younger than 12 months. At 6 and 9 months, the infant should be receiving breast milk or iron-fortified commercial infant formula. At age 18 months, milk and formula are supplemented with solid foods, water, and some fruit juices.

DIF: Cognitive Level: Understanding REF: p. 440 TOP: Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance

23. The mother of a 6-month-old infant has returned to work and is expressing breast milk to be frozen. She asks for directions on how to safely thaw the breast milk in the microwave. What should the nurse recommend?

a.

Heat only 10 oz or more.

b.

Do not thaw or heat breast milk in a microwave oven.

c.

Always leave the bottle top uncovered to allow heat to escape.

d.

Shake the bottle vigorously for at least 30 seconds after heating.

ANS: B

Using a microwave oven to thaw or heat breast milk decreases the anti-infective properties of the breast milk, lowers the vitamin C content, and changes the fat content. Breast milk should be thawed overnight in a refrigerator or in a warm water bath. A microwave should not be used. If steam is created, the milk is too hot. The bottle should be inverted several times after defrosting or warming.

DIF: Cognitive Level: Applying REF: p. 439

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

24. The parents of a 4-month-old infant tell the nurse that they are getting a microwave oven and will be able to heat the babys formula faster. What should the nurse recommend?

a.

Heat only 8 oz or more.

b.

Do not heat a plastic bottle in a microwave oven.

c.

Leave the bottle top uncovered to allow heat to escape.

d.

Shake the bottle vigorously for at least 30 seconds after heating.

ANS: C

If a microwave is being used, the bottle should be left uncovered. This will allow heat to escape. No more than 4 oz should be heated at any one time. Bottles can be heated safely in microwave ovens if safety guidelines are followed. The bottle should be inverted 10 times; vigorous shaking is not necessary.

DIF: Cognitive Level: Applying REF: p. 439

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

25. What is the best age to introduce solid food into an infants diet?

a.

2 to 3 months

b.

4 to 6 months

c.

When birth weight has tripled

d.

When tooth eruption has started

ANS: B

Physiologically and developmentally, 4- to 6-month-old infants are in a transition period. The extrusion reflex has disappeared, and swallowing is a more coordinated process. In addition, the gastrointestinal tract has matured sufficiently to handle more complex nutrients and is less sensitive to potentially allergenic food. Infants of this age will try to help during feeding. Two to 3 months is too young. The extrusion reflex is strong, and the child will push food out with the tongue. No research indicates that the addition of solid food to a bottle has any benefit. Infant birth weight doubles at 1 year. Solid foods can be started earlier. Tooth eruption can facilitate biting and chewing; most infant foods do not require this ability.

DIF: Cognitive Level: Understanding REF: p. 439 TOP: Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance

26. The parent of 2-week-old infant asks the nurse if fluoride supplements are necessary because the infant is exclusively breastfed. What is the nurses best response?

a.

The infant needs to begin taking them now.

b.

Supplements are not needed if you drink fluoridated water.

c.

The infant may need to begin taking them at age 6 months.

d.

The infant can have infant cereal mixed with fluoridated water instead of supplements.

ANS: C

Fluoride supplementation is recommended by the American Academy of Pediatrics beginning at age 6 months if the child is not drinking adequate amounts of fluoridated water. Supplementation is not recommended before age 6 months regardless of whether the mother drinks fluoridated water. Infant cereal is not recommended at 2 weeks of age.

DIF: Cognitive Level: Applying REF: p. 440

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

27. An infant, age 5 months, is brought to the clinic by his parents for a well-baby checkup. What is the best advice that the nurse should include at this time about injury prevention?

a.

Keep buttons, beads, and other small objects out of his reach.

b.

Do not permit him to chew paint from window ledges because he might absorb too much lead.

c.

When he learns to roll over, you must supervise him whenever he is on a surface from which he might fall.

d.

Lock the crib sides securely because he may stand and lean against them and fall out of bed.

ANS: A

Aspiration of foreign objects is a great risk at this age. Parents are instructed to keep small objects out of the infants reach. At this age, the child is not mobile enough to reach window sills. If window sills have cracked or chipped paint, it needs to be removed before he is a toddler. This child should already be rolling over. This information is reinforced but should have been taught earlier. Pulling to a stand occurs between 8 and 12 months of age.

DIF: Cognitive Level: Applying REF: p. 443

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

28. The parents of a 12-month-old child ask the nurse if the child can eat hot dogs as do their other children. The nurses reply should be based on what?

a.

The child is too young to digest hot dogs.

b.

The child is too young to eat hot dogs safely.

c.

Hot dogs must be sliced into sections to prevent aspiration.

d.

Hot dogs must be cut into small, irregular pieces to prevent aspiration.

ANS: D

To eat a hot dog safely, the child should be sitting down, and the hot dog should be cut into small, irregular pieces rather than served whole or in slices. The childs digestive system is mature enough to digest hot dogs. Hot dogs are of a consistency, diameter, and shape that may cause complete obstruction of the childs airway if not cut into irregular, small pieces.

DIF: Cognitive Level: Applying REF: p. 445

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

29. In teaching parents about appropriate pacifier selection, the nurse should recommend which characteristic?

a.

Easily grasped handle

b.

Detachable shield for cleaning

c.

Soft, pliable material

d.

Ribbon or string to secure to clothing

ANS: A

A good pacifier should be easily grasped by the infant. One-piece construction is necessary to avoid having the nipple and guard separate, posing a risk for aspiration. The material should be sturdy and flexible. If the pacifier is too pliable, it may be aspirated. No ribbon or string should be attached. This poses additional risks.

DIF: Cognitive Level: Applying REF: p. 436

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

30. The parent of an 8.2-kg (18-lb) 9-month-old infant is borrowing a federally approved car seat from the clinic. The nurse should explain that the safest way to put in the car seat is what?

a.

Front facing in back seat

b.

Rear facing in back seat

c.

Front facing in front seat with air bag on passenger side

d.

Rear facing in front seat if an air bag is on the passenger side

ANS: B

A rear-facing car seat provides the best protection for an infants disproportionately heavy head and weak neck. The middle of the back seat is the safest position for the child. Severe injuries and deaths in children have occurred from air bags deploying on impact in the front passenger seat.

DIF: Cognitive Level: Applying REF: p. 443

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

31. At an 8-month-old well-baby visit, the parent tells the nurse that her infant falls asleep at night during the last bottle feeding but wakes up when moved to the infants crib. What is the most appropriate response for the nurse to make?

a.

You should put your baby to sleep 1 hour earlier without the nighttime feeding but with a pacifier for soothing.

b.

You could place rice cereal in the last bottle feeding of the day to ensure a longer sleep pattern.

c.

You should have your partner give the last bottle of the day and observe whether your infant stays awake for your partner.

d.

You could increase daytime feeding intervals to every 4 hours and put your baby in the crib while the baby is still awake.

ANS: D

Increasing the daytime intervals to 4 hours and placing the baby in the crib while still awake are interventions for nighttime sleeping problems. Putting the baby to bed 1 hour earlier with a pacifier will not stop the need for the bedtime bottle; there is no research that rice cereal in the bottle helps to satisfy the baby longer at night, and switching partners does not guarantee that the baby will go to sleep better.

DIF: Cognitive Level: Applying REF: p. 441

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

32. The nurse is performing an assessment on a 12-month-old infant. Which fine or gross motor developmental skill demonstrates the proximodistal acquisition of skills?

a.

Standing

b.

Sitting without assistance

c.

Fully developed pincer grasp

d.

Taking a few steps holding onto something

ANS: C

Acquisition of fine and gross motor skills occurs in an orderly center-to-periphery (proximodistal) or head-to-toe (cephalocaudal) sequence. A fully developed pincer grasp is an example of the proximodistal development because infants use a palmar grasp before developing the finer pincer grasp. Standing, sitting without assistance, and taking a few steps are examples of a cephalocaudal development sequence.

DIF: Cognitive Level: Analyzing REF: p. 417

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

33. An infant weighed 8 lb at birth and was 18 inches in length. What weight and length should the infant be at 5 months of age?

a.

12 lb, 20 inches

b.

14 lb, 21.5 inches

c.

16 lb, 23 inches

d.

18 lb, 24.5 inches

ANS: C

Infants gain 680 g (1.5 lb) per month until age 5 months, when the birth weight has at least doubled. Height increases by 2.5 cm (1 inch) per month during the first 6 months. Therefore, at 5 months the infant should weigh 16 lb and be 23 inches in length.

DIF: Cognitive Level: Understanding REF: p. 413

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

34. The clinic nurse is teaching parents about physiologic anemia that occurs in infants. What statement should the nurse include about the cause of physiologic anemia?

a.

Maternally derived iron stores are depleted in the first 2 months.

b.

Fetal hemoglobin results in a shortened survival of red blood cells.

c.

The production of adult hemoglobin decreases in the first year of life.

d.

Low levels of fetal hemoglobin depress the production of erythropoietin.

ANS: B

Fetal hemoglobin results in a shortened survival of red blood cells (RBCs) and thus a decreased number of RBCs. Maternally derived iron stores are present for the first 5 to 6 months results in a shortened survival of RBCs and thus a decreased number of RBCs. High levels of fetal hemoglobin depress the production of erythropoietin, a hormone released by the kidney that stimulates RBC production.

DIF: Cognitive Level: Applying REF: p. 416

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

35. The nurse is teaching parents about expected language development for their 6-month-old infant. The nurse recognizes the parents understand the teaching if they make which statement?

a.

Our baby should comprehend the word no.

b.

Our baby knows the meaning of saying mama.

c.

Our baby should be able to say three to five words.

d.

Our baby should begin to combine syllables, such as dada.

ANS: D

By 6 months, infants imitate sounds; add the consonants t, d, and w; and combine syllables (e.g., dada), but they do not ascribe meaning to the word until 10 to 11 months of age. By 9 to 10 months, they comprehend the meaning of the word no and obey simple commands accompanied by gestures. By age 1 year, they can say three to five words with meaning and may understand as many as 100 words.

DIF: Cognitive Level: Applying REF: p. 426

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

36. The nurse is performing an assessment on a 10-week-old infant. The nurse understands that the developmental characteristic of hearing at this age is which?

a.

The infant responds to his own name.

b.

The infant localizes sounds by turning his head directly to the sound.

c.

The infant turns his head to the side when sound is made at the level of the ear.

d.

The infant locates sound by turning his head to the side and then looking up or down.

ANS: C

At 8 to 12 weeks of age, the infant turns the head to the side when sound is made at the level of the ear. At 16 to 24 weeks, the infant locates sound by turning the head to the side and then looking up or down. At 24 to 32 weeks, infants respond to their own name. At 32 to 40 weeks, the infant localizes sounds by turning the head directly toward the sound.

DIF: Cognitive Level: Understanding REF: p. 415

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

MULTIPLE RESPONSE

1. The nurse is teaching a group of parents at a community education program about introducing solid foods to their infants. Which recommendations should the nurse include? (Select all that apply.)

a.

Spoon feeding should be introduced after an entire milk feeding.

b.

It is best to introduce a wide variety of foods during the first year.

c.

As solid food consumption increases, the quantity of milk should decrease.

d.

Introduction of low-calorie milk and food should be done by the end of the first year.

e.

Introduction of citrus fruits, meats, and eggs should be delayed until after 6 months of age.

f.

Each new food item should be introduced at 5- to 7-day intervals.

ANS: B, C, E, F

Teaching related to feeding an infant solid foods should include introducing a wide variety of foods because an infant has not developed a strong food preference as seen with a toddler. As solid food consumption increases, the amount of milk consumed should decrease to less than 1 L/day to prevent overfeeding. Introduction to citrus fruits, meats, and eggs should be delayed until after 6 months of age because of the potential to cause food allergies. New foods should be introduced at 5- to 7-day intervals to evaluate for food allergies. Spoon feedings should be introduced after a small ingestion of milk, not at the end of a milk feeding, to associate the activity with pleasure. In general, low-calorie milk and food should be avoided.

DIF: Cognitive Level: Applying REF: p. 439

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

2. The nurse is providing anticipatory guidance to parents of a 4-month-old infant on preventing an aspiration injury. What should the nurse include in the teaching? (Select all that apply.)

a.

Keep baby powder out of reach.

b.

Inspect toys for removable parts.

c.

Allow the infant to take a bottle to bed.

d.

Teething biscuits can be used for teething discomfort.

e.

The infant should not be fed hard candy, nuts, or foods with pits.

ANS: A, B, E

Anticipatory guidance to prevent aspiration for a 4-month-old infant takes into account that the infant will begin to be more active and place objects in the mouth. Toys should be checked for removable parts; baby powder should be kept out of reach; and hard candy, nuts, and foods with pits should be avoided. The infant should not go to bed with a bottle. Teething biscuits should be used with caution because large chunks may be broken off and aspirated.

DIF: Cognitive Level: Applying REF: p. 443

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Safe and Effective Care Environment

3. The nurse is providing anticipatory guidance to parents of an 8-month-old infant on preventing a drowning injury. Which should the nurse include in the teaching? (Select all that apply.)

a.

Fence swimming pools.

b.

Keep bathroom doors open.

c.

Eliminate unnecessary pools of water.

d.

Keep one hand on the child while in the tub.

e.

Supervise the child when near any source of water.

ANS: A, C, D, E

Anticipatory guidance to prevent drowning for an 8-month-old infant takes into account that the child will begin to crawl, cruise around furniture, walk, and climb. Fences should be placed around swimming pools, unnecessary pools of water should be eliminated, one hand should be kept on the child when bathing, and the child should be supervised when near any source of water. The bathroom doors should be kept closed.

DIF: Cognitive Level: Applying REF: p. 443

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Safe and Effective Care Environment

4. The nurse is providing anticipatory guidance to the parents of a 1-month-old infant on preventing a suffocation injury. Which should the nurse include in the teaching? (Select all that apply.)

a.

Do not place pillows in the infants crib.

b.

Crib slats should be 4 inches or less apart.

c.

Keep all plastic bags stored out of the infants reach.

d.

Plastic over the mattress is acceptable if it is covered with a sheet.

e.

A pacifier should not be tied on a string around the infants neck.

ANS: A, C, E

Anticipatory guidance for a 1-month-old infant to prevent a suffocation injury takes into account that the infant will have increased eyehand coordination and a voluntary grasp reflex as well as a crawling reflex that may propel the infant forward or backward. Pillows should not be placed in the infants crib, plastic bags should be kept out of reach, and a pacifier should not be tied on a string around the neck. Crib slats should be 2.4 inches apart (4 inches is too wide), and the mattress should not be covered with plastic even if a sheet is used to cover it.

DIF: Cognitive Level: Applying REF: p. 443

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Safe and Effective Care Environment

5. The nurse is providing anticipatory guidance to parents of a 6-month-old on preventing an accidental poisoning injury. Which should the nurse include in the teaching? (Select all that apply.)

a.

Place plants on the floor.

b.

Place medications in a cupboard.

c.

Discard used containers of poisonous substances.

d.

Keep cosmetic and personal products out of the childs reach.

e.

Make sure that paint for furniture or toys does not contain lead.

ANS: C, D, E

Anticipatory guidance for a 7-month-old infant to prevent a suffocation injury takes into account that the infant will become more active and eventually crawl, cruise, and walk. Used containers of poisonous substances should be discarded, cosmetic and personal products should be kept out of the childs reach, and paint for furniture or toys should be lead free. Plants should be hung out of reach or placed on a high shelf. Medications should be locked, not just placed in a cupboard.

DIF: Cognitive Level: Applying REF: p. 443

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Safe and Effective Care Environment

6. The clinic nurse is assessing a 6-month-old infant during a well-child appointment. The nurse should use which approaches to alleviate the infants stranger anxiety? (Select all that apply.)

a.

Talk in a loud voice.

b.

Meet the infant at eye level.

c.

Avoid sudden intrusive gestures.

d.

Maintain a safe distance initially.

e.

Pick up the infant and hold him or her closely.

ANS: B, C, D

The best approaches for the nurse to alleviate the infants stranger anxiety are to talk softly; meet the infant at eye level (to appear smaller); maintain a safe distance from the infant; and avoid sudden, intrusive gestures, such as holding out the arms and smiling broadly. Talking in a loud voice and picking the infant up would increase the infants anxiety.

DIF: Cognitive Level: Applying REF: p. 426

TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

7. The nurse is evaluating a 7-month-old infants cognitive development. Which behaviors should the nurse anticipate evaluating? (Select all that apply.)

a.

Imitates sounds

b.

Shows interest in a mirror image

c.

Comprehends simple commands

d.

Actively searches for a hidden object

e.

Attracts attention by methods other than crying

ANS: A, B, E

A 7-month-old infant is in the secondary circular reactions (48 months) stage of cognitive development. Behaviors in this stage include imitating sounds, showing interest in a mirror image, and attracting attention by methods other than crying. Comprehending simple commands and actively searching for a hidden object are behaviors seen in the coordination of secondary schemas (912 months).

DIF: Cognitive Level: Applying REF: p. 431 TOP: Nursing Process: Evaluation

MSC: Client Needs: Health Promotion and Maintenance

8. The nurse is planning play activities for a 2-month-old hospitalized infant to stimulate the auditory sense. Which activities should the nurse implement? (Select all that apply.)

a.

Talk to the infant.

b.

Play a music box.

c.

Place a squeaky doll in the crib.

d.

Give the infant a small-handled clear rattle.

ANS: A, B, D

Auditory stimulation appropriate for a 2-month-old infant includes talking to the infant, playing a music box, and giving the infant a small-handled clear rattle. Placing a squeaky doll in the crib is appropriate for an infant 6 months of age or older.

DIF: Cognitive Level: Applying REF: p. 428

TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

MATCHING

Match each neurologic reflex that appears in infancy to its description.

a.

Labyrinth righting

b.

Body righting

c.

Otolith righting

d.

Landau

e.

Parachute

1. When the body of an erect infant is tilted, the head is returned to an upright, erect position.

2. An infant in the prone or supine position is able to raise his or her head.

3. Turning the hips and shoulders to one side causes all the other body parts to follow.

4. When the infant is suspended in a horizontal prone position and suddenly thrust downward, the hands and fingers extend forward as if to protect against falling.

5. When the infant is suspended in a horizontal prone position, the head is raised and the legs and spine are extended.

1. ANS: C DIF: Cognitive Level: Understanding REF: p. 414

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

2. ANS: A DIF: Cognitive Level: Understanding REF: p. 414

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

3. ANS: B DIF: Cognitive Level: Understanding REF: p. 414

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

4. ANS: E DIF: Cognitive Level: Understanding REF: p. 414

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

5. ANS: D DIF: Cognitive Level: Understanding REF: p. 414

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

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