Chapter 16: The Infant My Nursing Test Banks

Chapter 16: The Infant

Elsevier items and derived items 2007 by Saunders, an imprint of Elsevier Inc.

MULTIPLE CHOICE

1. A mother calls the pediatricians office because her infant is colicky. The helpful measure the nurse would suggest to the parent is:

a.

Sing songs to the infant in a soft voice.

b.

Place the infant in a well-lit room.

c.

Walk around and massage the infants back.

d.

Rock the fussy infant slowly and gently.

ANS: D

One technique the nurse can offer parents of a fussy infant is to rock the infant gently and slowly while being careful to avoid sudden movements.

DIF: Cognitive Level: Application REF: Text Reference: 390

OBJ: Objective: 11 TOP: Topic: Health Maintenance

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

2. The nurse is aware that the age at which the posterior fontanelle closes is:

a.

2 to 3 months

b.

3 to 6 months

c.

6 to 9 months

d.

9 to 12 months

ANS: A

The posterior fontanel closes between 2 and 3 months of age.

DIF: Cognitive Level: Knowledge REF: Text Reference: 384, Table 16-1

OBJ: Objective: 2 TOP: Topic: Development and Care

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

3. The nurse knows that an infants birthweight should be tripled by:

a.

9 months

b.

1 year

c.

18 months

d.

2 years

ANS: B

The infant usually triples his or her birth weight by about 12 months of age.

DIF: Cognitive Level: Knowledge REF: Text Reference: 386, Table 16-1

OBJ: Objective: 2 TOP: Topic: Development and Care

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

4. The nurse is aware that the age at which an infant is able to sit steadily alone is:

a.

4 months

b.

5 months

c.

8 months

d.

15 months

ANS: C

The infant can sit alone without support at about 8 months of age.

DIF: Cognitive Level: Knowledge REF: Text Reference: 382, Figure 16-3

OBJ: Objective: 2 TOP: Topic: Development and Care

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

5. The infant should be able to walk independently by the age of:

a.

8-10 months

b.

12-15 months

c.

15-18 months

d.

18-21 months

ANS: B

For the majority of children, the milestone of walking alone is achieved between 12 and 15 months.

DIF: Cognitive Level: Knowledge REF: Text Reference: 383, Table 16-3

OBJ: Objective: 2 TOP: Topic: Development and Care

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

6. The parent of a 3-month-old infant asks the nurse, At what age do infants usually begin drinking from a cup? The nurse would reply:

a.

5 months

b.

9 months

c.

1 year

d.

2 years

ANS: A

The infant can usually drink from a cup when it is offered at about 5 months.

DIF: Cognitive Level: Comprehension REF: Text Reference: 386, Table 16-1

OBJ: Objective: 7 TOP: Topic: Nutrition Counseling

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

7. The nurse would expect a 4-month-old to be able to:

a.

Hold a cup

b.

Stand with assistance

c.

Lift head and shoulders

d.

Sit with back straight

ANS: C

Because development is cephalocaudal, of these choices, sitting is the one that the infant learns to do first. The infant can usually sit with support at about 5 months of age and can sit alone at about 8 months.

DIF: Cognitive Level: Analysis REF: Text Reference: 381, Table 16-1

OBJ: Objective: 2 TOP: Topic: Development and Care

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

8. The abnormal finding in an evaluation of growth and development for a 6-month-old infant would be:

a.

Weight gain of 4-7 ounces per week

b.

Length increase of 1 inch in 2 months

c.

Head lag present

d.

Can sit alone for a few seconds

ANS: C

The infant should be holding the head up well by 5 months of age. If head lag is present at 6 months, the child should undergo further evaluation.

DIF: Cognitive Level: Analysis REF: Text Reference: 386, Table 16-1

OBJ: Objective: 2 TOP: Topic: Development and Care

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

9. A parent brings a 6-month-old infant to the pediatric clinic for her well-child examination. Her birthweight was 8 pounds, 2 ounces. The nurse weighing the infant today would expect her weight to be at least:

a.

12 pounds

b.

16 pounds

c.

20 pounds

d.

24 pounds

ANS: B

Birth weight is usually doubled by 6 months of age.

DIF: Cognitive Level: Application REF: Text Reference: 386, Table 16-1

OBJ: Objective: 8 TOP: Topic: Development and Care

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

10. The nurse would advise a parent when introducing solid foods to:

a.

Begin with one tablespoon of the food.

b.

Mix foods together.

c.

Eliminate a refused food from the diet.

d.

Introduce each new food 4 to 7 days apart.

ANS: D

Only one new food is offered in a 4- to 7-day period to determine tolerance.

DIF: Cognitive Level: Comprehension REF: Text Reference: 394

OBJ: Objective: 5 TOP: Topic: Nutrition Counseling

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

11. When talking with a parent about tooth eruption, the nurse explains that the first deciduous teeth to erupt are the:

a.

Lower central incisors

b.

Upper central incisors

c.

Lower lateral incisors

d.

Upper lateral incisors

ANS: A

The first teeth to erupt, usually at about 7 months, are the lower central incisors.

DIF: Cognitive Level: Knowledge REF: Text Reference: 387, Table 16-1

OBJ: Objective: 8 TOP: Topic: Development and Care

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

12. When assessing development in a 9-month-old infant, the nurse would expect to observe the infant:

a.

Sitting if supported

b.

Grasping objects with the palm

c.

Imitating sounds such as da-da

d.

Beginning to use a spoon rather sloppily

ANS: C

The 9-month-old tries to imitate sounds such as da-da or ba-ba.

DIF: Cognitive Level: Analysis REF: Text Reference: 388, Table 16-1

OBJ: Objective: 2 TOP: Topic: Development and Care

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

13. The statement made by a parent that indicates correct understanding of infant feeding is:

a.

Ive been mixing rice cereal and formula in the babys bottle.

b.

I switched the baby to low-fat milk at 9 months.

c.

The baby really likes little pieces of chocolate.

d.

I give the baby any new foods before he takes his bottle.

ANS: D

New solid foods should be introduced before formula or breast milk to encourage the infant to try new foods.

DIF: Cognitive Level: Analysis REF: Text Reference: 394

OBJ: Objective: 5 TOP: Topic: Nutrition Counseling

KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

14. The nurse would advise a mother who is concerned because her 10-month-old is lethargic, to:

a.

Keep the babys room well-lit.

b.

Rub the babys soles vigorously.

c.

Offer the baby a pacifier.

d.

Handle the infant slowly and gently.

ANS: D

Some infants respond to stimulating environments by shutting down. Move and handle infants slowly and gently.

DIF: Cognitive Level: Application REF: Text Reference: 390

OBJ: Objective: 11, 14 TOP: Topic: Health Maintenance

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

15. The nurse discusses safety-proofing the home with the mother of a 9-month-old. The statement made by the mother that indicates an unsafe behavior is:

a.

I put covers on all of the electrical outlets.

b.

In the car, she rides in a front-facing car seat.

c.

There are locks on all of the cabinets in the house.

d.

I have a gate at the top and bottom of the stairs.

ANS: B

A rear-facing infant car seat should be used for infants under 1 year of age.

DIF: Cognitive Level: Analysis REF: Text Reference: 396

OBJ: Objective: 13 TOP: Topic: Infant Safety

KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

16. The nurse observes a 10-month-old infant using her index finger and thumb to pick up Cheerios. This behavior is evidence that the infant has developed the:

a.

Pincer grasp

b.

Grasp reflex

c.

Prehension ability

d.

Parachute reflex

ANS: A

By 1 year, the pincer-grasp coordination of index finger and thumb is well established.

DIF: Cognitive Level: Analysis REF: Text Reference: 382, Figure16-3

OBJ: Objective: 2 TOP: Topic: General Characteristics

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

17. A parent is concerned because her infant has a diaper rash. The nurse would advise the parent to:

a.

Use commercial diaper wipes to clean the area.

b.

Apply a protective ointment on the area.

c.

Change the babys diaper less frequently.

d.

Keep the diaper area covered all of the time.

ANS: B

A protective ointment can be applied when the skin in the diaper area appears pink and irritated.

DIF: Cognitive Level: Application: Basic Care and Comfort

REF: Text Reference: 390 OBJ: Objective: 10

TOP: Topic: Community-Based Care KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

18. The mother of an infant born prematurely tells the nurse, The baby is irritable. He cries during diaper changes and feedings. Can you make some suggestions about what I should do to soothe him? The most appropriate recommendation to help this parent would be:

a.

Play the radio or TV while you feed the baby.

b.

Put the baby in a room with sunlight.

c.

Cover the baby snugly when you hold him.

d.

Change the babys position quickly.

ANS: C

A strategy that may be helpful is to swaddle the infant snugly in a light blanket with extremities flexed and hands near the face.

DIF: Cognitive Level: Application REF: Text Reference: 383

OBJ: Objective: 11 TOP: Topic: Community-Based Care

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

19. The most appropriate activity to recommend to parents to promote sensorimotor stimulation for a 1-year-old would be:

a.

Ride a tricycle.

b.

Spend time in an infant swing.

c.

Play with push-pull toys.

d.

Read large picture books.

ANS: C

Push-pull toys are appropriate to promote sensorimotor stimulation for a 1-year-old child.

DIF: Cognitive Level: Analysis REF: Text Reference: 397, Table 16-4

OBJ: Objective: 12 TOP: Topic: Infant Safety

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

20. The statement that indicates the mother of an 8-month-old understands infant sleep patterns is:

a.

I put the baby in my bed until she falls asleep, then I put her in her crib.

b.

I let the baby skip an afternoon nap so she will fall asleep earlier.

c.

I put the pacifier in the crib so she can find it when she wakes up.

d.

I rock the baby back to sleep if she wakes up at night.

ANS: C

The parent should assist the infant to develop self-soothing behaviors so the infant can get back to sleep on her own.

DIF: Cognitive Level: Analysis REF: Text Reference: 390

OBJ: Objective: 14 TOP: Topic: Health Maintenance

KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

MULTIPLE RESPONSE

1. The nurse is aware that the 7-month-old can signal feeding readiness by:

Select all that apply.

a.

Pulling spoon toward mouth

b.

Biting at spoon with upper and lower incisors

c.

Pointing to food bowl

d.

Bouncing up and down with excitement at sight of food

e.

Manipulating finger foods

ANS: A, E

The 7-month-old pulls the spoon toward its mouth, and can manipulate finger foods. The 7-month-old does not have upper incisors and has not developed adequately to recognize the food container or exhibit excitement related to the sight of food.

DIF: Cognitive Level: Analysis REF: Text Reference: 395, Table 16-4

OBJ: Objective: 2 TOP: Topic: Feeding Skills

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

COMPLETION

1. The nurse reminds the parents that the first DPT, oral polio, and flu immunizations should be given when the child is ____________________ months old.

ANS: 2

DIF: Cognitive Level: Comprehension REF: Text Reference: 384, Table 16-1

OBJ: Objective: 2 TOP: Topic: Immunizations

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

NOT: Rationale: The first DPT, polio, and flu immunizations are given at the age of 2 months.

2. The nurse explains the second process of self-mobility a baby learns is seen at the age of 9 months, when the baby begins to ____________________.

ANS: creep

DIF: Cognitive Level: Application REF: Text Reference: 388, Table 16-1

OBJ: Objective: 2 TOP: Topic: Creeping

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

NOT: Rationale: At 7 months the baby begins to crawl, using arms and dragging trunk and legs. At 9 months the baby begins to creep, holding its trunk above the floor. The next self-mobility activity is cruising, where the child walks from one piece of furniture to the next before it begins to walk independently.

3. The nurse cautions parents to place their baby in the ____________________ or ____________________ positions, rather than on its stomach, to reduce the risk of sudden infant death syndrome (SIDS).

ANS: supine or side-lying

DIF: Cognitive Level: Application REF: Text Reference: 390

OBJ: Objective: 10 TOP: Topic: Positions for Sleep

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk

NOT: Rationale: The supine or side-lying position has been found to reduce possible aspiration, and is believed to reduce the risk of SIDS.

OTHER

1. The nurse explains that a babys prehensile development is progressive and logical. Arrange the development in the order from the simplest to the most complex.

a. Hands held open most of the time

b. Grasps with thumb on one side and three fingers on the other

c. Picks up toy with squeeze action

d. Thumb and forefinger hold object

e. Hands held closed most of the time

ANS:

E, A, C, B, D

The development advances from the newborns closed hands to the open star hands of the older infant, to the squeeze action, to a grasp with thumb and fingers, to the pincher movement of thumb and forefinger.

DIF: Cognitive Level: Analysis REF: Text Reference: 382, Figure 16-3

OBJ: Objective: 2 TOP: Topic: Prehensile Development

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

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