Chapter 6: Health Promotion for the Infant My Nursing Test Banks

Chapter 6: Health Promotion for the Infant

Test Bank

MULTIPLE CHOICE

1. Which milestone is developmentally appropriate for a 2-month-old infant?

a.

Pulled to a sitting position, head lag is absent.

b.

Pulled to a sitting position, the infant is able to support the head when the trunk is lifted.

c.

The infant can lift his or her head from the prone position and briefly hold the head erect.

d.

In the prone position, the infant is fully able to support and hold the head in a straight line.

ANS: C

Feedback

A

A 2-month-old infants neck muscles are stronger than those of a newborn; however, head lag is present when pulled to a sitting position.

B

A 2-month-old infant continues to have some head lag when pulled to a sitting position.

C

A 2-month-old infant is able to briefly hold the head erect when in a prone position. If a parent were holding the infant against the parents shoulder, the infant would be able to lift his or her head briefly.

D

It is not until 4 months of age that the infant can easily lift his or her head and hold it steadily erect when in the prone position.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 93 | Table 6-1

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

2. Approximately how much would a newborn who weighed 7 pounds 6 ounces at birth weigh at 1 year of age?

a.

14 3/4 lb

b.

22 1/8 lb

c.

29 1/2 lb

d.

Unable to estimate weigh at 1 year

ANS: B

Feedback

A

An infant doubles birth weight by 6 months of age.

B

An infant triples birth weight by 1 year of age.

C

An infant quadruples birth weight by 2 years of age.

D

Weight at 6 months, 1 year, and 2 years of age can be estimated from the birth weight.

PTS: 1 DIF: Cognitive Level: Application REF: p. 94 | Table 6-1

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

3. Which statement made by a mother is 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

Feedback

A

An infant who responds to his name at 9 months of age is demonstrating abilities to both hear and interpret sound.

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.

C

A social smile is present by 2 months of age.

D

Rolling over in both directions is not a critical milestone for gross motor development until the child reaches 6 months of age.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 94 | Table 6-1

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

4. The nurse is performing a routine assessment on a 14-month-old infant and notes that the anterior fontanel is closed. This should be interpreted as a(n)

a.

Normal finding

b.

Questionable findinginfant should be rechecked in 1 month

c.

Abnormal findingindicates need for immediate referral to practitioner

d.

Abnormal findingindicates need for developmental assessment

ANS: A

Feedback

A

This is a normal finding. The anterior fontanel closes between ages 12 and 18 months. The posterior fontanel closes between 2 and 3 months of age.

B

Because the anterior fontanel normally closes between ages 12 and 18 months, this is a normal finding, and no further intervention is required.

C

Because the anterior fontanel normally closes between ages 12 and 18 months, this is a normal finding, and no further intervention is required.

D

Because the anterior fontanel normally closes between ages 12 and 18 months, this is a normal finding, and no further intervention is required.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 94

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

5. The nurse advises the mother of a 3-month-old exclusively breastfed infant 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 breastfeeding without any supplements.

ANS: A

Feedback

A

Breast milk does not provide an adequate amount of dietary vitamin D. Infants who are exclusively breastfed need vitamin D supplements to prevent rickets.

B

An infant feeder is an inappropriate method of providing the infant with caloric intake. Solid foods are not recommended for a 3-month-old infant.

C

Rice cereal and other solid foods are contraindicated in a 3-month-old infant. Solid feedings do not typically begin before 4 to 6 months of age.

D

Because breast milk is not an adequate source of fluoride, infants need to be given a fluoride supplement in addition to a vitamin D supplement.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 100

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

6. At what age is an infant first expected to locate an object hidden from view?

a.

4 months of age

b.

6 months of age

c.

9 months of age

d.

20 months of age

ANS: C

Feedback

A

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.

B

Six-month-old infants have not developed the ability to perceive objects as permanent and do not search out objects hidden from their view.

C

By 9 months of age, an infant will actively search for an object that is out of sight.

D

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 age 9 months.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 97

OBJ: Nursing Process: Assessment MSC: Client Needs: 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. What is the nurses best response?

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

Feedback

A

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.

B

Grandparents can be supportive but are not the primary decision makers for the infant.

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.

D

Telling parents that they are making a mistake is an inappropriate response.

PTS: 1 DIF: Cognitive Level: Application REF: p. 99

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

8. The mother of a 9-month-old infant is concerned because the infant cries when approached by an unknown shopper at the grocery store. What is the best response for the nurse to make to the mother?

a.

You could consider leaving the infant more often with other people 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 is a sign of stranger anxiety and demonstrates healthy attachment.

ANS: D

Feedback

A

An infant who manifests stranger anxiety is showing a normal sign of healthy attachment. This behavior peaks at 7 to 9 months and is developmentally appropriate. The mother leaving the child more often will not change this developmental response to new strangers.

B

Assessing developmental needs is appropriate before taking an infant to a physician.

C

Pain from teething expressed by the infants cries would not occur only when the mother left the room.

D

The nurse can reassure parents that healthy attachment is manifested by stranger anxiety in late infancy.

PTS: 1 DIF: Cognitive Level: Application REF: p. 99

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

9. Which statement concerning physiologic factors is true?

a.

The infant has a slower metabolic rate than an adult.

b.

An infant has an inability to digest protein and lactase.

c.

Infants have a slower circulatory response than adults do.

d.

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

ANS: D

Feedback

A

The infants metabolic rate is faster, not slower, than an adults.

B

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.

C

Circulation is faster in infants than in adults.

D

The infants kidneys are not as effective at concentrating urine compared with an adults because of immaturity of the renal system and slower glomerular filtration rates. This puts the infant at greater risk for fluid and electrolyte imbalance.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 95

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

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

a.

Increased appetite from secondary growth spurt

b.

Encouraging the infant to smile

c.

Securing a developmentally safe environment for the infant

d.

Strategies to teach infants to sit up

ANS: C

Feedback

A

The infants appetite and growth velocity decrease in the second half of infancy.

B

Although a social smile should be present by 6 months of age, encouraging this is not of higher priority than ensuring environmental safety.

C

Safety is a primary concern as an infant becomes increasingly mobile.

D

Unless the infant has a neuromuscular deficit, strategies for teaching a normally developing infant to sit up are not necessary.

PTS: 1 DIF: Cognitive Level: Comprehension REF: pp. 95-96

OBJ: Nursing Process: Implementation MSC: Client Needs: 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

Feedback

A

Infants typically do not need more caloric intake to improve sleep behaviors.

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.

C

Keeping intake, output, waking, and sleeping data is not typically helpful to discuss differences among infants behaviors.

D

Just because an infant may not sleep as much as a sibling did does not justify labeling the child as being difficult. Identifying an infant as difficult without identifying helpful actions is not a therapeutic response for a parent concerned about sleep.

PTS: 1 DIF: Cognitive Level: Application REF: p. 107

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

12. The mother of a 10-month-old infant tells the nurse that her infant really likes cows milk. What is the nurses 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

Feedback

A

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.

B

It is best to wait until the infant is at least 1 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.

C

Bedtime bottles of formula or milk are contraindicated because of their high sugar content, which leads to dental decay in primary teeth.

D

Cereal can be mixed with formula.

PTS: 1 DIF: Cognitive Level: Application REF: p. 100

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

13. The mother of a 10-month-old infant asks the nurse about beginning to wean her child from his 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

Feedback

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.

B

When the child is taking more fluids from a cup and decreasing amounts from the bottle, the child is demonstrating a readiness for weaning.

C

Chewing on the nipple is another sign that the infant is ready to be weaned.

D

Consistent sucking is a sign that the child is not ready to be weaned.

PTS: 1 DIF: Cognitive Level: Application REF: p. 101

OBJ: Nursing Process: Assessment MSC: Client Needs: 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

Feedback

A

Six-month-old children enjoy playing pat-a-cake and peek-a-boo.

B

Nine-month-old infants enjoy rolling a ball and playing hide-and-seek games.

C

Four-month-old infants enjoy bright rattles and tactile toys.

D

Twelve-month-old infants enjoy playing with push and pull toys.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 93 | Table 6-1

OBJ: Nursing Process: Assessment MSC: Client Needs: 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 weighs only 11 pounds. I expected her to have gained some weight.

d.

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

ANS: B

Feedback

A

Children who are ready to manage solid foods are able to move food to the back of their throats to swallow. This childs extrusion reflex may still be present.

B

Sitting is a sign that the child is ready to begin with solid foods.

C

Infants who weigh less than 13 pounds and demonstrate a lack of interest in eating are not ready to be started on solid foods.

D

Infants who are difficult feeders and do not demonstrate an interest in solid foods are not ready to be started on them.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 102, Box 6-3

OBJ: Nursing Process: Assessment MSC: Client Needs: 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 to make?

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

Feedback

A

An infants teeth need to be cleaned as soon as they erupt. Waiting until all the baby teeth are in is inappropriate and prolongs cleaning until 2 years of age.

B

Because toothpaste contains fluoride and infants will swallow the toothpaste, parents should avoid its use.

C

The infants teeth need to be cleaned by the parent as soon as they erupt. Even when a child has the ability to hold a toothbrush, the parent should continue cleaning the childs teeth.

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.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 105

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

17. A 3-month-old infant born at 38 weeks of gestation will hold a rattle if it is put in her hands, but she will not voluntarily grasp it. The nurse should interpret this as

a.

Normal development

b.

Significant developmental lag

c.

Slightly delayed development as a result of prematurity

d.

Suggestive of a neurologic disorder such as cerebral palsy

ANS: A

Feedback

A

This is indicative of normal development. Reflexive grasping occurs during the first 2 to 3 months and then gradually becomes voluntary.

B

The infant is expected to be able to perform this task by age 3 months. If the childs age is corrected because of being 2 weeks preterm, the child is at the midpoint of the range for this developmental task.

C

The infant is expected to be able to perform this task by age 3 months. If the childs age is corrected because of being 2 weeks preterm, the child is at the midpoint of the range for this developmental task.

D

The child is age-appropriate. No evidence of neurologic dysfunction is present.

PTS: 1 DIF: Cognitive Level: Application REF: p. 93 | Table 6-1

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

18. In terms of fine motor development, what should the 7-month-old infant be able to do?

a.

Transfer objects from one hand to the other.

b.

Use thumb and index finger in crude pincer grasp.

c.

Hold crayon and make a mark on paper.

d.

Release cubes into a cup.

ANS: A

Feedback

A

By age 7 months, infants can transfer objects from one hand to the other, crossing the midline.

B

The crude pincer grasp is apparent at approximately age 9 months.

C

The child can scribble spontaneously at age 15 months.

D

At age 12 months, the child can release cubes into a cup.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 93 | Table 6-1

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

19. In terms of gross motor development, what would the nurse expect a 5-month-old infant to do?

a.

Roll from abdomen to back.

b.

Roll from back to abdomen.

c.

Sit erect without support.

d.

Move from prone to sitting position.

ANS: A

Feedback

A

Rolling from abdomen to back is developmentally appropriate for a 5-month-old infant.

B

The ability to roll from back to abdomen usually occurs at 6 months old.

C

Sitting erect without support is a developmental milestone usually achieved by 8 months.

D

The 10-month-old infant can usually move from a prone to a sitting position.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 93 | Table 6-1

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

20. According to Piaget, the 6-month-old infant is in what stage of the sensorimotor phase?

a.

Use of reflexes

b.

Primary circular reactions

c.

Secondary circular reactions

d.

Coordination of secondary schemata

ANS: C

Feedback

A

The use of reflexes is primarily during the first month of life.

B

Primary circular reaction stage marks the replacement of reflexes with voluntary acts. The infant is in this stage from age 1 month to 4 months.

C

Infants are usually in the secondary circular reaction stage from age 4 months to 8 months. This stage is characterized by a continuation of the primary circular reaction because of the response that results. Shaking is performed to hear the noise of the rattle, not just for shaking.

D

The fourth sensorimotor stage is coordination of secondary schemata. This is a transitional stage in which increasing motor skills enable greater exploration of the environment.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 97

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

21. A mother tells the nurse that she is discontinuing breastfeeding her 5-month-old infant. The nurse should recommend that the infant be given

a.

Skim milk

b.

Whole cows milk

c.

Commercial iron-fortified formula

d.

Commercial formula without iron

ANS: C

Feedback

A

Cows milk should not be used in children younger than 12 months.

B

Cows milk should not be used in children younger than 12 months.

C

For children younger than 1 year, the American Academy of Pediatrics recommends the use of breast milk. If breastfeeding has been discontinued, then iron-fortified commercial formula should be used.

D

Maternal iron stores are almost depleted by this age; the iron-fortified formula will help prevent the development of iron-deficiency anemia.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 101

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

22. The parent of 2-week-old Sarah asks the nurse whether Sarah needs fluoride supplements, because she is exclusively breastfed. The nurses best response is

a.

She needs to begin taking them now.

b.

They are not needed if you drink fluoridated water.

c.

She may need to begin taking them at age 6 months.

d.

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

ANS: C

Feedback

A

The recommendation is to begin supplementation at 6 months.

B

The amount of water that is ingested and the amount of fluoride in the water are considered when supplementation is being considered.

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.

D

The amount of water that is ingested and the amount of fluoride in the water are considered when supplementation is being considered.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 105

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

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

Feedback

Correct

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.

Incorrect

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.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 96

OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance

2. Hearing seems to be relatively acute, even at birth, as shown by reflexive generalized reaction to noise. All newborns should undergo hearing screening at birth, before hospital discharge. In addition, assessment for hearing deficits should take place at every well-baby visit. Risk factors for hearing loss include (select all that apply)

a.

Structural abnormalities of the ear

b.

Family history of hearing loss

c.

Alcohol or drug use by the mother during pregnancy

d.

Gestational diabetes

e.

Trauma

ANS: A, B, E

Feedback

Correct

Structural abnormalities of the ear, a family history of hearing loss, and trauma are risk factors for hearing loss. Other risk factors include persistent otitis media and developmental delay. The American Academy of Pediatrics suggests that infants who demonstrate hearing loss be eligible for early intervention and specialized hearing and language services.

Incorrect

Prenatal alcohol or drug intake and gestational diabetes are not risk factors for hearing loss in the infant.

PTS: 1 DIF: Cognitive Level: Application REF: p. 97

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

COMPLETION

1. The nurse has just assisted in the delivery of a female infant to first-time parents.

The infant is suctioned, dried, and placed skin-to-skin on her mothers chest. This allows for significant interaction between mother and baby and is known as _____________.

ANS:

attachment

Parent-infant attachment is one of the most important aspects of infant psychosocial development. Initiated immediately after birth, attachment is strengthened by many mutually satisfying interactions between parents and their infant during the first few months of life. Attachment is a sense of belonging or connection with each other.

PTS: 1 DIF: Cognitive Level: Application REF: p. 99

OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

TRUE/FALSE

1. The rate of Sudden Infant Death Syndrome (SIDS), now the third leading cause of death in infants, has increased despite international efforts and the Back to Sleep campaign. Is this statement true or false?

ANS: F

This statement is incorrect. SIDS, which for a long time was the second leading cause of infant deaths, has decreased in part because of the Back to Sleep program. It is important for both hospital and clinic nurses to educate parents on safe sleep strategies for their infant.

PTS: 1 DIF: Cognitive Level: Application REF: p. 92

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

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