Chapter 16: The Infant Nursing School Test Banks

Chapter 16: The Infant

MULTIPLE CHOICE

1. A mother calls the pediatricians office because her infant is colicky. What is the most helpful measure the nurse can suggest to the mother?
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: Page 394-395
OBJ: 7 TOP: Colic KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

2. When does the posterior fontanelle close?
a. 2 to 3 months
b. 3 to 6 months
c. 6 to 9 months
d. 9 to 12 months
ANS: A
The posterior fontanelle closes between 2 and 3 months of age.

DIF: Cognitive Level: Knowledge REF: Page 390, Box 16-1
OBJ: 5 TOP: Fontanelle KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

3. At what age does an infants birth weight triple?
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: Page 394, Box 16-1
OBJ: 3 TOP: Development and Care
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

4. What is the earliest age at which an infant is able to sit steadily alone?
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: Page 392, Table 16-1
OBJ: 5 TOP: Sitting Alone
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

5. What is the earliest age at which the infant should be able to walk independently?
a. 8 to 10 months
b. 12 to 15 months
c. 15 to 18 months
d. 18 to 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: Page 394, Table 16-1
OBJ: 5 TOP: Walk Independently
KEY: Nursing Process Step: Data Collection
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? What is the nurses most accurate response?
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: Page 391 OBJ: 9 | 14
TOP: Drink from Cup KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

7. What would the nurse expect a 4-month-old to be able to accomplish?
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, lifting the head and shoulders 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: Comprehension REF: Page 391, Box 16-1
OBJ: 3 TOP: Development and Care
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

8. What is an abnormal finding in an evaluation of growth and development for a 6-month-old infant?
a. Weight gain of 4 to 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: Page 391-392, Box 16-1
OBJ: 3 TOP: Head Control
KEY: Nursing Process Step: Data Collection
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-baby examination. Her birth weight was 8 pounds, 2 ounces. What will the nurse weighing the infant today would expect her weight to be?
a. At least 12 pounds
b. At least 16 pounds
c. At least 20 pounds
d. At least 24 pounds
ANS: B
Birth weight is usually doubled by 6 months of age.

DIF: Cognitive Level: Application REF: Page 391, Box 16-1
OBJ: 3 TOP: Development and Care
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

10. What will the nurse advise a parent to do when introducing solid foods?
a. Begin with one tablespoon of 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: Page 401 OBJ: 15
TOP: Solid Food KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

11. The nurse is talking with a parent about tooth eruption. What teeth will the nurse explain are the first deciduous teeth to erupt?
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: Page 392, Table 16-1
OBJ: 5 TOP: Development and Care
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

12. The nurse is assessing development in a 9-month-old infant. What would the nurse expect to observe?
a. Speaking in 2-word sentences
b. Grasping objects with palmar grasp
c. Creeping along the floor
d. Beginning to use a spoon rather sloppily
ANS: C
The 9-month-old tries to creep, has developed pincer movement, and can grasp a spoon without keeping food on it.

DIF: Cognitive Level: Analysis REF: Page 393, Table 16-1
OBJ: 3 TOP: Development and Care
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

13. What statement made by a parent indicates correct understanding of infant feeding?
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: Comprehension REF: Page 401, Nursing Tip
OBJ: 15 TOP: Nutrition Counseling
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

14. A mother is concerned because her 10-month-old is lethargic. What is the best action the nurse can advise this mother to implement?
a. Keep the infants room well lit.
b. Rub the infants soles vigorously.
c. Offer the infant 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: Page 395 OBJ: 6
TOP: Lethargy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

15. The nurse discusses child-proofing the home for safety with the mother of a 9-month-old. Which statement made by the mother would indicate an unsafe behavior?
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 younger than 1 year of age.

DIF: Cognitive Level: Analysis REF: Page 403 OBJ: 17
TOP: 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 pieces of cereal. What does this behavior indicate the infant has developed?
a. The pincer grasp
b. A grasp reflex
c. Prehension ability
d. The parachute reflex
ANS: A
By 1 year, the pincer-grasp coordination of index finger and thumb is well established.

DIF: Cognitive Level: Comprehension REF: Page 387, 392, Table 16-1
OBJ: 3 TOP: General Characteristics
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

17. A parent is concerned because her infant has a diaper rash. What is the best action the nurse would advise the parent to implement?
a. Use commercial diaper wipes to clean the area.
b. Apply a protective ointment on the area.
c. Change the infants 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 REF: Page 396 OBJ: 6
TOP: Diaper Rash KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

18. The mother of an infant born prematurely tells the nurse, The baby is irritable. She cries during diaper changes and feedings. Can you make some suggestions about what I should do to soothe her? What is the most appropriate recommendation to help this parent?
a. Play the radio or TV while you feed the infant.
b. Put the infant in a room with sunlight.
c. Wrap the infant snugly when you hold them.
d. Change the infants 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: Page 394-395
OBJ: 7 TOP: Infant Care KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

19. What is the most appropriate activity to recommend to parents to promote sensorimotor stimulation for a 1-year-old?
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: Page 404, Table 16-4
OBJ: 18 TOP: Infant Safety
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

20. Which statement indicates the mother of an 8-month-old understands infant sleep patterns?
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 that she will fall asleep earlier.
c. I put the pacifier in the crib so that 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 that the infant can get back to sleep on her own.

DIF: Cognitive Level: Analysis REF: Page 396 OBJ: 8
TOP: Sleep Patterns KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

21. How might the nurse demonstrate the parachute reflex with an infant?
a. Lifting the infant high in the air above her head
b. Holding the infant in a football hold, cradling the head
c. Seating the infant in a stroller in an upright position
d. Thrusting the infant downward into the crib
ANS: D
The infant, when thrust downward in a prone position, will protectively extend the arms.

DIF: Cognitive Level: Comprehension REF: Page 387 OBJ: 3
TOP: Parachute Reflex KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

22. Parents of a 6-month-old infant ask the nurse why it is necessary to offer iron-rich formula to their child. What is the correct response?
a. The infant has limited ability to produce red blood cells.
b. The infant has ineffective digestive enzymes.
c. The infant has exhausted maternal iron stores.
d. The infant has need of the iron to support dentition.
ANS: C
Many pediatricians recommend iron-fortified formulas because maternal iron stores decrease by 6 months of age.

DIF: Cognitive Level: Comprehension REF: Page 398 OBJ: 15
TOP: Iron Supplement KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

23. The nurse is assessing a 1-year-old infant in the pediatric office. What finding should the nurse report to the physician immediately?
a. Respiratory rate of 60 breaths per minute
b. Pulse rate of 100 beats per minute
c. Minimal verbalization
d. Fussy behavior
ANS: A
Respirations of a 1-year-old should be 20 to 40 breaths per minute. Increased respiratory rate can lead to distress and should be reported immediately. Pulse rate of 100 to 140 beats/minute is normal. Minimal verbalization and fussy behavior are not emergency situations or abnormal for this age.

DIF: Cognitive Level: Application REF: Page 394, Box 16-1
OBJ: 2 TOP: 12-Month-Old Physical Characteristics
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

24. A new mother is voicing concern she is breastfeeding her newborn too frequently. How often does the nurse instruct this mother she should expect her newborn to feed?
a. Every 2 to 3 hours
b. Every 4 to 6 hours
c. Every 6 to 8 hours
d. Every 8 to 10 hours
ANS: A
Breastfed infants may require feedings at 2- to 3-hour intervals because breast milk is more easily digested. A flexible but regular schedule that provides a rest period between feedings is best for the parent and infant.

DIF: Cognitive Level: Application REF: Page 397 OBJ: 11
TOP: 12-Month-Old Physical Characteristics
KEY: Nursing Process Step: Intervention
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

MULTIPLE RESPONSE

25. The nurse cautions that children who have unmet hunger needs will likely display which characteristic(s)? (Select all that apply.)
a. Irritability
b. Ineffective feeding patterns
c. No predictable sleep-wake cycle
d. Distrust
e. Effective parent bonding
ANS: A, B, C, D
Children who experience frequent hunger do not have effective parental bonding. All other options are probable outcomes for a child who has unmet hunger needs.

DIF: Cognitive Level: Comprehension REF: Page 398, Table 16-2
OBJ: 3 TOP: Hunger KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

26. The nurse is preparing to outline principles of discipline for parents of an infant. What information should the nurse include? (Select all that apply.)
a. Firmly say No.
b. Distract the child to another activity.
c. Bribe the child with a sweet treat.
d. Remain consistent.
e. Ignore the child until behavior improves.
ANS: A, B, D
Parental approval is important to the infant, and setting limits early is important (Anderson, 2008). Principles of discipline for an infant include lowering the voice to say no firmly, removing the child from the situation, distraction, and consistency.

DIF: Cognitive Level: Comprehension REF: Page 387, Nursing Tip
OBJ: 4 TOP: Discipline KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

27. What should the teaching plan include about infant fall precautions? (Select all that apply.)
a. Remove all unsteady furniture.
b. Keep crib rails up and in locked position.
c. Steady infant with hand when on changing table.
d. Use tray attachment on high chair as restraint.
e. Keep infant seat on the floor.
ANS: A, B, C, E
The tray attachment to a high chair is an inadequate restraint. All other options are good precautions to prevent an infant from a fall.

DIF: Cognitive Level: Comprehension REF: Page 403 OBJ: 16 | 17
TOP: Fall Prevention KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk

28. The nurse is aware that the 7-month-old can signal feeding readiness by which action(s)? (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 his or her 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: Comprehension REF: Page 398, Table 16-2 | Page 402, Figure 16-4
OBJ: 3 TOP: Feeding Skills
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

29. The nurse is educating parents of a 2-month-old about immunizations. What immunizations against illness should their child receive? (Select all that apply.)
a. Pertussis (whooping cough)
b. Influenza
c. Diptheria
d. Tetanus
e. Polio
ANS: A, B, C, D, E
The first DPT, polio, and flu immunizations are given at the age of 2 months.

DIF: Cognitive Level: Knowledge REF: Page 390, Box 16-1
OBJ: 6 TOP: Immunizations
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection

30. What will the nurse take into consideration when educating parents regarding infant nutrition? (Select all that apply.)
a. Cultural practices
b. Sex of the infant
c. Parental knowledge
d. Infants developmental level
e. Parent-child interaction
ANS: A, C, D, E
Parents have many concerns about feeding their infant during the first year of life. This is a period when readiness to receive nutrition education is usually high; therefore the nurse looks for opportunities to provide accurate information. Assessment of parental knowledge; infant development, behavior, and readiness; parent-child interaction; and cultural and ethnic practices is important. Sex of the infant does not enter into nutritional education.

DIF: Cognitive Level: Comprehension REF: Page 397, Box 16-1, Chapter 15
OBJ: 10 TOP: Nutrition KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

31. Parents of an infant inform the nurse they are planning home preparation of solid foods. What directions should the nurse provide? (Select all that apply.)
a. Boil foods in a large amount of water.
b. Do not freeze foods.
c. Add 1 teaspoon of salt per cup.
d. Puree food in electric blender.
e. Add sugar sparingly.
ANS: D, E
Home-prepared infant food can be strained and pureed in an electric blender. Sugar should be added sparingly. Food should be boiled in small amounts of water and not over cooked to avoid destroying nutrients. Foods may be frozen in ice cube trays and defrosted for use.

DIF: Cognitive Level: Comprehension REF: Page 401, Health Promotion
OBJ: 12 | 13 TOP: Nutrition KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

COMPLETION

32. The nurse explains that the second process of self-mobility an infant learns is seen at the age of 9 months, when the infant begins to ___________.

ANS:
creep

At 7 months the infant begins to crawl, using arms and dragging trunk and legs. At 9 months the infant begins to creep, holding his or her 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.

DIF: Cognitive Level: Application REF: Page 389, Figure 16-3
OBJ: 3 TOP: Creeping KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

33. The nurse cautions parents to place their infant in the ______________ position, rather than on his or her stomach, to reduce the risk of sudden infant death syndrome (SIDS).

ANS:
supine

The supine or side-lying position has been found to reduce possible aspiration and is believed to reduce the risk of SIDS.

DIF: Cognitive Level: Application REF: Page 395 OBJ: 16
TOP: Positions for Sleep KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk

34. ______________ is characterized by periods of unexplained irritability and crying in a healthy, well-fed infant.

ANS:
Colic

Colic is characterized by periods of unexplained irritability and crying in a healthy, well-fed infant.

DIF: Cognitive Level: Knowledge REF: Page 395 OBJ: 1
TOP: Colic KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

35. The nurse explains that an infants prehensile development is progressive and logical. Arrange the development in the order from the simplest to the most complex. Put a comma and space between each answer choice (a, b, c, d, etc.)

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: Page 388-389, Figure 16-3
OBJ: 3 TOP: Prehensile Development
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

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