Chapter 31: The Infant and Family Nursing School Test Banks

Chapter 31: The Infant and Family

MULTIPLE CHOICE

1. Which statement best describes the infants physical development?

a.

Anterior fontanel closes by age 6 to 10 months.

b.

Binocularity is well established by age 8 months.

c.

Birth weight doubles by age 5 months and triples by age 1 year.

d.

Maternal iron stores persist during the first 12 months of life.

ANS: C

Growth is very rapid during the first year of life. The birth weight approximately doubles by age 5 to 6 months and triples by age 1 year. The anterior fontanel closes at age 12 to 18 months. Binocularity is not established until age 15 months. Maternal iron stores are usually depleted by age 6 months.

PTS: 1 DIF: Cognitive Level: Analysis REF: 866

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

2. The nurse is assessing a 6-month-old healthy infant who weighed 7 pounds at birth. The nurse should expect the infant to now weigh approximately:

a.

10 pounds.

c.

20 pounds.

b.

15 pounds.

d.

25 pounds.

ANS: B

Birth weight doubles at about age 5 to 6 months. At 6 months, an infant who weighed 7 pounds at birth would weigh approximately 15 pounds. Ten pounds is too little; the infant would have gone from the 50th percentile at birth to below the 5th percentile. Twenty pounds or more is too much; the infant would have tripled the birth weight at 6 months.

PTS: 1 DIF: Cognitive Level: Analysis REF: 866

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

3. The nurse is doing a routine assessment on a 14-month-old infant and notes that the anterior fontanel is closed. This should be interpreted as:

a.

A normal finding.

b.

A questionable findingthe infant should be rechecked in 1 month.

c.

An abnormal findingindicates the need for immediate referral to a practitioner.

d.

An abnormal findingindicates the need for developmental assessment.

ANS: A

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: 869

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

4. By what age does the posterior fontanel usually close?

a.

6 to 8 weeks

c.

4 to 6 months

b.

10 to 12 weeks

d.

8 to 10 months

ANS: A

The bones surrounding the posterior fontanel fuse and close by age 6 to 8 weeks. Ten weeks or longer is too late.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 864

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

5. The parents of a 9-month-old infant tell the nurse that they have noticed foods such as peas and corn are not completely digested and can be seen in their infants stool. The nurse bases her explanation on knowing that:

a.

Children should not be given fibrous foods until the digestive tract matures at age 4 years.

b.

The infant should not be given any solid foods until this digestive problem is resolved.

c.

This is abnormal and requires further investigation.

d.

This is normal because of the immaturity of digestive processes at this age.

ANS: D

The immaturity of the digestive tract is evident in the appearance of the stools. Solid foods are passed incompletely broken down in the feces. An excess quantity of fiber predisposes the child to large, bulky stools. This is a normal part of the maturational process, and no further investigation is necessary.

PTS: 1 DIF: Cognitive Level: Application REF: 870

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

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

a.

Normal development.

b.

Significant developmental lag.

c.

Slightly delayed development caused by prematurity.

d.

Suggestive of a neurologic disorder such as cerebral palsy.

ANS: A

This indicates normal development. Reflexive grasping occurs during the first 2 to 3 months and then gradually becomes voluntary. No evidence of developmental lag, delayed development, or neurologic dysfunction is present.

PTS: 1 DIF: Cognitive Level: Application REF: 871

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

7. In terms of fine motor development, the infant of 7 months should be able to:

a.

Transfer objects from one hand to the other.

b.

Use thumb and index finger in a crude pincer grasp.

c.

Hold a crayon and make a mark on paper.

d.

Release cubes into a cup.

ANS: A

By age 7 months, infants can transfer objects from one hand to the other, crossing the midline. The crude pincer grasp is apparent at about age 9 months. The infant can scribble spontaneously at age 15 months. At age 12 months, the infant can release cubes into a cup.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 871

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

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

a.

Roll from abdomen to back.

c.

Sit erect without support.

b.

Roll from back to abdomen.

d.

Move from prone to sitting position.

ANS: A

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

PTS: 1 DIF: Cognitive Level: Comprehension REF: 872

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

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

a.

4 months

c.

8 months

b.

6 months

d.

10 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.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 872

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

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

a.

6 months

c.

9 months

b.

8 months

d.

11 to 12 months

ANS: C

Most infants can pull themselves to a standing position at age 9 months. Any infant who cannot pull to a standing position by age 11 to 12 months should be referred for further evaluation for developmental dysplasia of the hip. At 6 months, the infant has just obtained coordination of arms and legs. By age 8 months, infants can bear full weight on their legs.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 872

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

11. According to Piaget, the 6-month-old infant would be in what stage of the sensorimotor phase?

a.

Use of reflexes

c.

Secondary circular reactions

b.

Primary circular reactions

d.

Coordination of secondary schemata

ANS: 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 for the response that results. For example, shaking of a rattle is performed to hear the noise of the rattle, not just for shaking. The use of reflexes 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 age 1 month to 4 months. 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: 875

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

12. Which behavior indicates that an infant has developed object permanence?

a.

Recognizes familiar face such as the mother

b.

Recognizes familiar object such as a bottle

c.

Actively searches for a hidden object

d.

Secures objects by pulling on a string

ANS: C

During the first 6 months of life, infants believe that objects exist only as long as they can see them. When infants search for an object that is out of sight, this signals the attainment of object permanence, whereby an infant knows that an object exists even when it is not visible. Between ages 8 and 12 weeks, infants begin to respond differentially to their mothers. They cry, smile, vocalize, and show distinct preference for their mothers. This preference is one of the stages that influence the attachment process, but it is too early for object permanence. Recognizing familiar objects is an important transition for the infant, but it does not signal object permanence. The ability to understand cause and effect, such as pulling on a string to secure an object, is part of secondary schema development.

PTS: 1 DIF: Cognitive Level: Analysis REF: 875

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

13. A parent asks the nurse At what age do most babies begin to fear strangers? The nurse responds that most infants begin to fear strangers at age:

a.

2 months.

c.

6 months.

b.

4 months.

d.

12 months.

ANS: C

Between ages 6 and 8 months, fear of strangers and stranger anxiety become prominent and are related to the infants ability to discriminate between familiar and nonfamiliar people. At age 2 months, the infant is just beginning to respond differentially to the mother. At age 4 months, the infant is beginning the process of separation individuation when the infant begins to recognize self and mother as separate beings. Twelve months is too late and requires referral for evaluation if the infant does not fear strangers at this age.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 877

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

14. The nurse is interviewing the father of 10-month-old Megan. She is playing on the floor when she notices an electrical outlet and reaches up to touch it. Her father says No firmly and removes her from near the outlet. The nurse should use this opportunity to teach the father that Megan:

a.

Is old enough to understand the word No.

b.

Is too young to understand the word No.

c.

Should already know that electrical outlets are dangerous.

d.

Will learn safety issues better if she is spanked.

ANS: A

By age 10 months, children are able to associate meaning with words. The child should be old enough to understand the word No. The 10-month-old is too young to understand the purpose of an electrical outlet. The father is using both verbal and physical cues to teach safety measures and alert the child to dangerous situations. Physical discipline should be avoided.

PTS: 1 DIF: Cognitive Level: Analysis REF: 905

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

15. Sara, age 4 months, was born at 35 weeks gestation. She seems to be developing normally, but her parents are concerned because she is a more difficult baby than their other child, who was term. The nurse should explain that:

a.

Infants temperaments are part of their unique characteristics.

b.

Infants become less difficult if they are not kept on scheduled feedings and structured routines.

c.

Saras behavior is suggestive of failure to bond completely with her parents.

d.

Saras difficult temperament is the result of painful experiences in the neonatal period.

ANS: A

Infant temperament has a strong biologic component. Together with interactions with the environment, primarily the family, the biologic component contributes to the infants unique temperament. Children perceived as difficult may respond better to scheduled feedings and structured caregiving routines than to demand feedings and frequent changes in routines. Saras temperament has been created by both biologic and environmental factors. The nurse should provide guidance in parenting techniques that are best suited to Saras temperament.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 878

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

16. Which information could be given to the parents of a 12-month-old child regarding appropriate play activities for this age?

a.

Give large push-pull toys for kinesthetic stimulation.

b.

Place cradle gym across crib to facilitate fine motor skills.

c.

Provide child with finger paints to enhance fine motor skills.

d.

Provide stick horse to develop gross motor coordination.

ANS: A

The 12-month-old child is able to pull to a stand and walk holding on or independently. Appropriate toys for a child of this age include large push-pull toys for kinesthetic 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.

PTS: 1 DIF: Cognitive Level: Analysis REF: 878

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

17. An appropriate play activity for a 7-month-old infant to encourage visual stimulation is:

a.

Playing peek-a-boo.

c.

Imitating animal sounds.

b.

Playing pat-a-cake.

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 will help with kinesthetic stimulation. Imitating animal sounds will help with auditory stimulation.

PTS: 1 DIF: Cognitive Level: Analysis REF: 878

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

18. The best play activity to provide tactile stimulation for a 6-month-old infant is to:

a.

Allow to splash in bath.

c.

Play music box, tapes, or CDs.

b.

Give various colored blocks.

d.

Use infant swing or stroller.

ANS: A

The feel of the water while the infant is splashing provides tactile stimulation. Various colored blocks provide visual stimulation for a 4- to 6-month-old infant. A music box, tapes, and CDs provide auditory stimulation. Swings and strollers provide kinesthetic stimulation.

PTS: 1 DIF: Cognitive Level: Analysis REF: 875

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

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

a.

1 month

c.

3 months

b.

2 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. The 3-month-old can recognize familiar faces. At age 4 months, the infant can enjoy social interactions.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 876

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

20. Latasha is a breastfed infant being seen in the clinic for her 6-month checkup. Her mother tells the nurse that Latasha recently began to suck her thumb. The best nursing intervention is to:

a.

Recommend that the mother substitute a pacifier for Latashas thumb.

b.

Assess Latasha for other signs of sensory deprivation.

c.

Reassure the mother that this is very normal at this age.

d.

Suggest that the mother breastfeed Latasha more often to satisfy sucking needs.

ANS: C

Sucking is an infants chief pleasure, and she may not be satisfied by bottle-feeding or breastfeeding alone. During infancy and early childhood, there is no need to restrict nonnutritive sucking. Dental damage does not appear to occur unless the use of the pacifier or finger persists after age 4 to 6 years. The nurse should explore with the mother her feelings about pacifier vs. thumb. This is a normal behavior to meet nonnutritive sucking needs. No data support that Latasha has sensory deprivation.

PTS: 1 DIF: Cognitive Level: Application REF: 880

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

21. Austin, age 6 months, has six teeth. The nurse should recognize that this is:

a.

Normal tooth eruption.

c.

Unusual and dangerous.

b.

Delayed tooth eruption.

d.

Earlier-than-normal tooth eruption.

ANS: D

This is earlier than expected. Most infants at age 6 months have two teeth. Six teeth at 6 months is not delayed; it is early tooth eruption. Although unusual, it is not dangerous.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 881

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

22. The nurse notices that a 10-month-old infant being seen in the clinic is wearing expensive, inflexible, high-top shoes. The nurse should explain that:

a.

Soft and flexible shoes are generally better.

b.

High-top shoes are necessary for support.

c.

Inflexible shoes are necessary to prevent in-toeing and out-toeing.

d.

This type of shoe will encourage the infant to walk sooner.

ANS: A

The main purpose of the shoe is protection. Soft, well-constructed, athletic-type shoes are best for infants and children. High-top shoes are not necessary for support but may be helpful keeping the childs foot in the shoe. Inflexible shoes can delay walking, aggravate in-toeing and out-toeing, and impede development of the supportive foot muscles.

PTS: 1 DIF: Cognitive Level: Analysis REF: 901

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

23. 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.

c.

Commercial iron-fortified formula.

b.

Whole cows milk.

d.

Commercial formula without iron.

ANS: C

For children younger than 1 year, the American Academy of Pediatrics recommends the use of breast milk. If breastfeeding has been discontinued, iron-fortified commercial formula should be used. Cows milk should not be used in children younger than 12 months. 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: 882

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

24. When is the best age for solid food to be introduced into the infants diet?

a.

2 to 3 months

c.

When birth weight has tripled

b.

4 to 6 months

d.

When tooth eruption has started

ANS: B

Physiologically and developmentally, the 4- to 6-month-old is 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 infant will push food out with the tongue. No research base indicates that the addition of solid food to bottle-feeding has any benefit. Tooth eruption can facilitate biting and chewing; most infant foods do not require this ability.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 882

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

25. 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. The nurse should recommend:

a.

Never heating a bottle in a microwave oven.

b.

Heating only 10 ounces or more.

c.

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

d.

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

ANS: A

Neither infant formula nor breast milk should be warmed in a microwave oven as this may cause oral burns as a result of uneven heating in the container. The bottle may remain cool while hot spots develop in the milk. Warming expressed milk in a microwave decreases the availability of antiinfective properties and causes separation of the fat content. Milk should be warmed in a lukewarm water bath.

PTS: 1 DIF: Cognitive Level: Analysis REF: 883

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

26. Parents tell the nurse that their 1-year-old son often sleeps with them. They seem unconcerned about this. The nurses response should be based on the knowledge that:

a.

Children should not sleep with their parents.

b.

Separation from parents should be completed by this age.

c.

Daytime attention should be increased.

d.

This is a common and accepted practice, especially in some cultural groups.

ANS: D

Co-sleeping or sharing the family bed, in which the parents allow the children to sleep with them, is a common and accepted practice in many cultures. Parents should evaluate the options available and avoid conditions that place the infant at risk. Population-based studies are currently underway; no evidence at this time supports or abandons the practice for safety reasons. This is the age at which children are just beginning to individuate. Increased daytime activity may help decrease sleep problems in general, but co-sleeping is a culturally determined phenomenon.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 911

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

27. The parent of 2-week-old Sarah asks the nurse if 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

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. The recommendation is to begin supplementation at 6 months, not at 2 weeks. The amount of water that is ingested and the amount of fluoride in the water are evaluated when supplementation is being considered.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 883

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

28. A mother tells the nurse that she doesnt want her infant immunized because of the discomfort associated with injections. The nurse should explain that:

a.

This cannot be prevented.

b.

Infants do not feel pain as adults do.

c.

This is not a good reason for refusing immunizations.

d.

A topical anesthetic, eutectic mixture of local anesthetic (EMLA), can be applied before injections are given.

ANS: D

Several topical anesthetic agents can be used to minimize the discomfort associated with immunization injections. These include EMLA and vapor coolant sprays. Pain associated with many procedures can be prevented or minimized by using the principles of atraumatic care. With preparation, the injection site can be properly anesthetized to decrease the amount of pain felt by the infant. Infants have the neural pathways to sense pain. Numerous research studies have indicated that infants perceive and react to pain in the same manner as do children and adults. The mother should be allowed to discuss her concerns and the alternatives available. This is part of the informed consent process.

PTS: 1 DIF: Cognitive Level: Analysis REF: 895

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

29. The parents of a 12-month-old child ask the nurse if the child can eat hot dogs. The nurses reply should be based on knowing that:

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

Hot dogs are of a consistency, diameter, and round shape that may cause complete obstruction of the childs airway. If given to young children, 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. To eat the hot dog safely, the child should be sitting down, and the hot dog should be appropriately cut into irregularly shaped pieces.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 900

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

30. The clinic is lending a federally approved car seat to an infants family. The nurse should explain that the safest place to put the car seat is:

a.

Front facing in back seat.

b.

Rear facing in back seat.

c.

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

d.

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

ANS: B

The rear-facing car seat provides the best protection for an infants disproportionately heavy head and weak neck. Infants should face the rear from birth to 20 pounds and as close to 1 year of age as possible. The middle of the back seat provides the safest position. Severe injuries and deaths in children have occurred from air bags deploying on impact in the front passenger seat.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 900

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

31. A nurse is teaching parents about prevention and treatment of colic. Which should the nurse include in the teaching plan?

a.

Avoid use of pacifiers.

b.

Eliminate all secondhand smoke contact.

c.

Lay infant flat after feeding.

d.

Avoid swaddling the infant.

ANS: B

To prevent and treat colic, teach parents that if household members smoke, they should avoid smoking near the infant; smoking activity should preferably be confined to outside of the home. A pacifier can be introduced for added sucking. The infant should be swaddled tightly with a soft, stretchy blanket and placed in an upright seat after feedings.

PTS: 1 DIF: Cognitive Level: Application REF: 905

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

32. A parent of an infant with colic tells the nurse, All this baby does is scream at me; it is a constant worry. The nurses best action is:

a.

Encourage parent to verbalize feelings.

b.

Encourage parent not to worry so much.

c.

Assess parent for other signs of inadequate parenting.

d.

Reassure parent that colic rarely lasts past age 9 months.

ANS: A

Colic is multifactorial, and no single treatment is effective for all infants. The parent is verbalizing concern and worry. The nurse should allow the parent to put these feelings into words. An empathic, gentle, and reassuring attitude, in addition to suggestions about remedies, will help alleviate the parents anxieties. The nurse should reassure the parent that he or she is not doing anything wrong. The infant with colic is experiencing spasmodic pain that is manifested by loud crying, in some cases up to 3 hours each day. Telling the parent that it will eventually go away does not help him or her through the current situation.

PTS: 1 DIF: Cognitive Level: Application REF: 906

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

33. Parent guidelines for relieving colic in an infant include:

a.

Avoiding touching the abdomen.

b.

Avoiding using a pacifier.

c.

Changing the infants position frequently.

d.

Placing the infant where the family cannot hear the crying.

ANS: C

Changing the infants position frequently may be beneficial. The parent can walk holding the infant face down and with the infants chest across the parents arm. The parents hand can support the infants abdomen, applying gentle pressure. Gently massaging the abdomen is effective in some infants. Pacifiers can be used for meeting additional sucking needs. The infant should not be placed where monitoring cannot be done. The infant can be placed in the crib and allowed to cry. Periodically, the infant should be picked up and comforted.

PTS: 1 DIF: Cognitive Level: Application REF: 907

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

34. Clinical manifestations of failure to thrive caused by behavioral problems resulting in inadequate intake of calories include:

a.

Avoidance of eye contact.

b.

An associated malabsorption defect.

c.

Weight that falls below the 15th percentile.

d.

Normal achievement of developmental landmarks.

ANS: A

One of the clinical manifestations of nonorganic failure to thrive is the childs avoidance of eye contact with the health professional. A malabsorption defect would result in a physiologic problem, not behavioral. Weight (but not height) below the 5th percentile is indicative of failure to thrive. Developmental delays, including social, motor, adaptive, and language, exist.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 909

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

35. Which is an important nursing consideration when caring for an infant with failure to thrive?

a.

Establish a structured routine and follow it consistently.

b.

Maintain a nondistracting environment by not speaking to the infant during feeding.

c.

Place the infant in an infant seat during feedings to prevent overstimulation.

d.

Limit sensory stimulation and play activities to alleviate fatigue.

ANS: A

The infant with failure to thrive should have a structured routine that is followed consistently. Disruptions in other activities of daily living can have a great impact on feeding behaviors. Bathing, sleeping, dressing, playing, and feeding are structured. The nurse should talk to the infant by giving directions about eating. This will help the infant maintain focus. Young children should be held while being fed, and older children can sit at a feeding table. The infant should be fed in the same manner at each meal. The infant can engage in sensory and play activities at times other than mealtime.

PTS: 1 DIF: Cognitive Level: Application REF: 910

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

36. An important nursing responsibility when dealing with a family experiencing the loss of an infant from sudden infant death syndrome (SIDS) is to:

a.

Explain how SIDS could have been predicted and prevented.

b.

Interview parents in depth concerning the circumstances surrounding the infants death.

c.

Discourage parents from making a last visit with the infant.

d.

Make a follow-up home visit to parents as soon as possible after the infants death.

ANS: D

A competent, qualified professional should visit the family at home as soon as possible after the death and provide the family with printed information about SIDS. An explanation of how SIDS could have been predicted and prevented is inappropriate. SIDS cannot be prevented or predicted. Discussions about the cause will only increase parental guilt. The parents should be asked only factual questions to determine the cause of death. Parents should be allowed and encouraged to make a last visit with their infant.

PTS: 1 DIF: Cognitive Level: Application REF: 910

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

37. Which is the most appropriate action when an infant becomes apneic?

a.

Shake vigorously.

b.

Roll head side to side.

c.

Hold by feet upside down with head supported.

d.

Gently stimulate trunk by patting or rubbing.

ANS: D

If the infant is apneic, the infants trunk should be gently stimulated by patting or rubbing. If the infant is prone, turn onto the back. The infant should not be shaken vigorously, have the head rolled side to side, or be held by the feet upside down with the head supported. These actions can cause injury.

PTS: 1 DIF: Cognitive Level: Application REF: 916

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

38. With the goal of preventing plagiocephaly, the nurse should teach new parents to:

a.

Place the infant prone for 30 to 60 minutes per day.

b.

Buy a soft mattress.

c.

Allow the infant to nap in the car safety seat.

d.

Have the infant sleep with the parents.

ANS: A

Prevention of positional plagiocephaly may begin shortly after birth by implementing prone positioning or tummy time for approximately 30 to 60 minutes per day when the infant is awake. Soft mattresses or sleeping with parents (co-sleeping) are not recommended because they put the infant at a higher risk for a sudden infant death incident. To prevent plagiocephaly, prolonged placement in car safety seats should be avoided.

PTS: 1 DIF: Cognitive Level: Application REF: 912

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

39. An infant has been pronounced dead from sudden infant death syndrome (SIDS) in the emergency department. Which is an appropriate question to ask the parents?

a.

Did you hear the infant cry out?

b.

Why didnt you check on the infant earlier?

c.

What time did you find the infant?

d.

Was the head buried in a blanket?

ANS: C

During a SIDS incident, if the infant is not pronounced dead at the scene, he or she may be transported to the emergency department to be pronounced dead by a physician. While they are in the emergency department, the parents are asked only factual questions, such as when they found the infant, how he or she looked, and whom they called for help. The nurse avoids any remarks that may suggest responsibility, such as Why didnt you go in earlier? Didnt you hear the infant cry out? or Was the head buried in a blanket?

PTS: 1 DIF: Cognitive Level: Application REF: 912

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

40. An infant experienced an apparent life-threatening event and is being placed on home apnea monitoring. The parents have understood the instructions for use of a home apnea monitor when they state:

a.

We can adjust the monitor to eliminate false alarms.

b.

We should sleep in the same bed as our monitored infant.

c.

We will check the monitor several times a day to be sure the alarm is working.

d.

We will place the monitor in the crib with our infant.

ANS: C

The parents should check the monitor several times a day to be sure the alarm is working and that it can be heard from room to room. The parents should not adjust the monitor to eliminate false alarms. Adjustments could compromise the monitors effectiveness. The monitor should be placed on a firm surface away from the crib and drapes. The parents should not sleep in the same bed as the monitored infant.

PTS: 1 DIF: Cognitive Level: Application REF: 912

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

41. The parents of a 3-month-old infant report that their infant sleeps supine (face up) but is often prone (face down) while awake. The nurses response should be based on knowledge that this is:

a.

Unacceptable because of the risk of sudden infant death syndrome (SIDS).

b.

Unacceptable because it does not encourage achievement of developmental milestones.

c.

Unacceptable to encourage fine motor development.

d.

Acceptable to encourage head control and turning over.

ANS: D

These parents are implementing the guidelines to reduce the risk of SIDS. Infants should sleep on their backs and then be placed on their abdomens when awake to enhance development of milestones such as head control. The face-down position while awake and positioning on the back for sleep are acceptable because they reduce risk of SIDS and allow achievement of developmental milestones. These position changes encourage gross motor, not fine motor, development.

PTS: 1 DIF: Cognitive Level: Analysis REF: 871

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

42. The nurse should teach parents that which age is safe to give infants whole milk instead of commercial infant formula?

a.

6 months

c.

12 months

b.

9 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 commercial infant formula or breast milk. At age 18 months, milk and formula are supplemented with solid foods, water, and some fruit juices.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 883

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

43. A parent asks the nurse whether her infant is susceptible to pertussis. The nurses response should be based on which statement concerning susceptibility to pertussis?

a.

Neonates will be immune the first few months.

b.

If the mother has had the disease, the infant will receive passive immunity.

c.

Children younger than 1 year seldom contract this disease.

d.

Most children are highly susceptible from birth.

ANS: D

The acellular pertussis vaccine is recommended by the American Academy of Pediatrics beginning at age 6 weeks. Infants are at greater risk for complications of pertussis. The vaccine is not given after age 7 years, when the risks of the vaccine become greater than those of pertussis. The infant is highly susceptible to pertussis, which can be a life-threatening illness in this age-group.

PTS: 1 DIF: Cognitive Level: Application REF: 890

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

MULTIPLE RESPONSE

44. Pacifiers can be extremely dangerous because of the frequency of use and the intensity of the infants suck. In teaching parents about appropriate pacifier selection, the nurse should explain that a pacifier should have which characteristics (select all that apply)?

a.

Easily grasped handle

b.

One-piece construction

c.

Ribbon or string to secure to clothing

d.

Soft, pliable material

e.

Sturdy, flexible material

ANS: A, B, E

A good pacifier should be easily grasped by the infant. One-piece construction is necessary to avoid having the nipple and guard separate. The material should be sturdy and flexible. An attached ribbon or string and soft, pliable material are not characteristics of a good pacifier.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 900

OBJ: Nursing Process: Planning

MSC: Client Needs: Safe and Effective Care Environment

45. In terms of gross motor development, what would the nurse expect a 5-month-old infant to do (select all that apply)?

a.

Roll from abdomen to back.

b.

Put feet in mouth when supine.

c.

Roll from back to abdomen.

d.

Sit erect without support.

e.

Move from prone to sitting position.

ANS: A, B

Rolling from abdomen to back and placing the feet in the mouth when supine are developmentally appropriate for a 5-month-old infant. Rolling from back to abdomen is developmentally appropriate for a 6-month-old infant. An 8-month-old infant should be able to sit erect without support. A 10-month-old infant can usually move from a prone to a sitting position.

PTS: 1 DIF: Cognitive Level: Application REF: 872

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

46. A nurse is conducting education classes for parents of infants. The nurse plans to discuss sudden infant death syndrome (SIDS). Which risk factors should the nurse include as increasing an infants risk of a SIDS incident(select all that apply)?

a.

Breastfeeding

b.

Low Apgar scores

c.

Male sex

d.

Birth weight in the 50th or higher percentile

e.

Recent viral illness

ANS: B, C, E

Certain groups of infants are at increased risk for SIDS: those with low birth weight, low Apgar scores, or recent viral illness, and those of male sex. Breastfed infants and infants of average or above-average weight are not at higher risk for SIDS.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 911

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

47. Which interventions should the nurse implement when caring for a family of a sudden infant death syndrome (SIDS) infant (select all that apply)?

a.

Allow parents to say goodbye to their infant.

b.

Once parents leave the hospital, no further follow-up is required.

c.

Arrange for someone to take the parents home from the hospital.

d.

Avoid requesting an autopsy of the deceased infant.

e.

Conduct a debriefing session with the parents before they leave the hospital.

ANS: A, C, E

An important aspect of compassionate care for parents experiencing a SIDS incident is allowing them to say good-bye to their infant. These are the parents last moments with their infant, and they should be as quiet, meaningful, peaceful, and undisturbed as possible. Because the parents leave the hospital without their infant, it is helpful to accompany them to the car or arrange for someone else to take them home. A debriefing session may help health care workers who dealt with the family and deceased infant to cope with emotions that are often engendered when a SIDS victim is brought into the acute care facility. An autopsy may clear up possible misconceptions regarding the death. When the parents return home, a competent, qualified professional should visit them after the death as soon as possible.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 913

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

48. A nurse is preparing to administer routine immunizations to a 4-month-old infant. The infant is currently up to date on all previously recommended immunizations. Which immunizations will the nurse prepare to administer (select all that apply)?

a.

Measles, mumps, and rubella (MMR)

b.

Rotavirus (RV)

c.

Diphtheria, tetanus, and acellular pertussis (DTaP)

d.

Varicella

e.

Haemophilus influenzae type b (HIB)

f.

Inactivated poliovirus (IPV)

ANS: B, C, E, F

The recommended immunization schedule for a 4-month-old, up to date on immunizations, would be to administer the RV, DTaP, HIB, and IPV vaccinations. The MMR and varicella vaccinations would not be administered until the child is at least 1 year of age.

PTS: 1 DIF: Cognitive Level: Application REF: 886

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

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

a.

We will put plastic fillers in all electrical plugs.

b.

We will place poisonous substances in a high cupboard.

c.

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

d.

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

e.

We will remove front knobs from the stove.

ANS: A, C, E

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

PTS: 1 DIF: Cognitive Level: Analysis REF: 905

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

MATCHING

Place in order the expected sequence of fine motor developmental milestones for an infant, beginning with the first milestone achieved and ending with the last milestone achieved.

a.

Voluntary palmar grasp

d.

Neat pincer grasp

b.

Reflex palmar grasp

e.

Builds a tower of two blocks

c.

Puts objects into a container

50. First

51. Second

52. Third

53. Fourth

54. Fifth

50. ANS: B PTS: 1 DIF: Cognitive Level: Analysis

REF: 868 OBJ: Nursing Process: Evaluation

MSC: Client Needs: Health Promotion and Maintenance

NOT: Grasping occurs during the first 2 to 3 months as a reflex and gradually becomes voluntary. By 5 months, infants are able to voluntarily grasp objects. Gradually, the palmar grasp (using the whole hand) is replaced by a pincer grasp (using the thumb and index finger). By 8 to 10 months of age, infants use a crude pincer grasp, and by 11 months, they have progressed to a neat pincer grasp. By 11 months, they put objects into containers and like to remove them. By age 1 year, infants try to build towers of two blocks.

51. ANS: A PTS: 1 DIF: Cognitive Level: Analysis

REF: 868 OBJ: Nursing Process: Evaluation

MSC: Client Needs: Health Promotion and Maintenance

NOT: Grasping occurs during the first 2 to 3 months as a reflex and gradually becomes voluntary. By 5 months, infants are able to voluntarily grasp objects. Gradually, the palmar grasp (using the whole hand) is replaced by a pincer grasp (using the thumb and index finger). By 8 to 10 months of age, infants use a crude pincer grasp, and by 11 months, they have progressed to a neat pincer grasp. By 11 months, they put objects into containers and like to remove them. By age 1 year, infants try to build towers of two blocks.

52. ANS: D PTS: 1 DIF: Cognitive Level: Analysis

REF: 868 OBJ: Nursing Process: Evaluation

MSC: Client Needs: Health Promotion and Maintenance

NOT: Grasping occurs during the first 2 to 3 months as a reflex and gradually becomes voluntary. By 5 months, infants are able to voluntarily grasp objects. Gradually, the palmar grasp (using the whole hand) is replaced by a pincer grasp (using the thumb and index finger). By 8 to 10 months of age, infants use a crude pincer grasp, and by 11 months, they have progressed to a neat pincer grasp. By 11 months, they put objects into containers and like to remove them. By age 1 year, infants try to build towers of two blocks.

53. ANS: C PTS: 1 DIF: Cognitive Level: Analysis

REF: 868 OBJ: Nursing Process: Evaluation

MSC: Client Needs: Health Promotion and Maintenance

NOT: Grasping occurs during the first 2 to 3 months as a reflex and gradually becomes voluntary. By 5 months, infants are able to voluntarily grasp objects. Gradually, the palmar grasp (using the whole hand) is replaced by a pincer grasp (using the thumb and index finger). By 8 to 10 months of age, infants use a crude pincer grasp, and by 11 months, they have progressed to a neat pincer grasp. By 11 months, they put objects into containers and like to remove them. By age 1 year, infants try to build towers of two blocks.

54. ANS: E PTS: 1 DIF: Cognitive Level: Analysis

REF: 868 OBJ: Nursing Process: Evaluation

MSC: Client Needs: Health Promotion and Maintenance

NOT: Grasping occurs during the first 2 to 3 months as a reflex and gradually becomes voluntary. By 5 months, infants are able to voluntarily grasp objects. Gradually, the palmar grasp (using the whole hand) is replaced by a pincer grasp (using the thumb and index finger). By 8 to 10 months of age, infants use a crude pincer grasp, and by 11 months, they have progressed to a neat pincer grasp. By 11 months, they put objects into containers and like to remove them. By age 1 year, infants try to build towers of two blocks.

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