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Chapter 10: Health Promotion of the Infant and Family

MULTIPLE CHOICE

1.A nurse is assessing a 12-month-old infant. Which statement best describes the infants physical development a nurse should expect to find?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:CGrowth is very rapid during the first year of life. The birth weight has approximately doubled 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:1DIF:Cognitive Level: UnderstandREF:309TOP:Integrated Process: Nursing Process: AssessmentMSC:Area of Client Needs: Health Promotion and Maintenance: Growth and Development

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 how many pounds?a.10b.15c.20d.25

ANS:BBirth weight doubles at about age 5 to 6 months. At 6 months, a child who weighed 7 pounds at birth would weigh approximately 15 pounds; 10 pounds is too little. The infant would have gone from the 50th percentile at birth to below the 5th percentile; 20 to 25 pounds is too much. The infant would have tripled the birth weight at 6 months.

PTS:1DIF:Cognitive Level: UnderstandREF:309TOP:Integrated Process: Nursing Process: AssessmentMSC:Area of Client Needs: Health Promotion and Maintenance: Growth and Development

3.The nurse is doing a routine assessment on a 14-month-old infant and notes that the anterior fontanel is closed. The nurse should interpret this as a(n):a.normal finding.b.finding requiring a referral.c.abnormal finding.d.normal finding, but requires rechecking in 1 month.

ANS:AThis is a normal finding. The anterior fontanel closes between ages 12 and 18 months. No further intervention is required.

PTS:1DIF:Cognitive Level: ApplyREF:309TOP:Integrated Process: Nursing Process: AssessmentMSC:Area of Client Needs: Health Promotion and Maintenance

4.A nurse is assessing a 6-month-old infant. The nurse recognizes the posterior fontanel usually closes at which age?a.6 to 8 weeksb.10 to 12 weeksc.4 to 6 monthsd.8 to 10 months

ANS:AThe bones surrounding the posterior fontanel fuse and close by age 6 to 8 weeks; 10 to 12 weeks, 4 to 6 months, and 8 to 10 months are too late. The posterior fontanel is usually closed by age 8 weeks.

PTS:1DIF:Cognitive Level: RememberREF:309TOP:Integrated Process: Nursing Process: AssessmentMSC:Area of 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 stools. The nurses explanation of this is based on which statement?a.Child should not be given fibrous foods until digestive tract matures at age 4 years.b.Child 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:DThe 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 normal for the child and is a normal part of the maturational process; no further investigation is necessary.

PTS:1DIF:Cognitive Level: ApplyREF:309TOP:Integrated Process: Teaching/LearningMSC:Area of 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, but she will not voluntarily grasp it. The nurse should interpret this as:a.normal development.b.significant developmental lag.c.slightly delayed development due to prematurity.d.suggestive of a neurologic disorder such as cerebral palsy.

ANS:AHolding a rattle but not voluntarily grasping it is indicative of normal development. Reflexive grasping occurs during the first 2 to 3 months and then gradually becomes voluntary. 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 and the behavior is age appropriate. No evidence of neurologic dysfunction is present.


7.In terms of fine motor development, what should the infant of 7 months be able to do?a.Transfer objects from one hand to the other and bang cubes on a table.b.Use thumb and index finger in crude pincer grasp and release an object at will.c.Hold a crayon between the fingers and make a mark on paper.d.Release cubes into a cup and build a tower of two blocks.

ANS:ABy age 7 months, infants can transfer objects from one hand to the other, crossing the midline, and bang objects on a hard surface. The crude pincer grasp is apparent at about age 9 months, and releasing an object at will is seen around 8 months. The child can scribble spontaneously at age 15 months. At age 12 months, the child can release cubes into a cup and build a small tower.

PTS:1DIF:Cognitive Level: UnderstandREF:315TOP:Integrated Process: Nursing Process: AssessmentMSC:Area of Client Needs: Health Promotion and Maintenance

8.At what age can most infants sit steadily unsupported?a.4 monthsb.6 monthsc.8 monthsd.10 months

ANS:CSitting 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.


9.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.acceptable to encourage fine motor development.d.acceptable to encourage head control and turning over.

ANS:DThese 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 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:1DIF:Cognitive Level: AnalyzeREF:315-316TOP:Integrated Process: Teaching/LearningMSC:Area of Client Needs: Health Promotion and Maintenance

10.By which age should the nurse expect an infant to be able to pull to a standing position?a.6 monthsb.8 monthsc.11 to 12 monthsd.14 to 15 months

ANS:CMost infants can pull themselves to a standing position at age 9 months. Infants who are not able to pull themselves to standing by age 11 to 12 months should be further evaluated for developmental dysplasia of the hip. At 6 months, infants have just obtained coordination of arms and legs. By age 8 months, infants can bear full weight on their legs. Any infant who cannot pull to a standing position by age 1 year should be referred for further evaluation.


11.According to Piaget, the 6-month-old infant should be in which developmental stage?a.Use of reflexesb.Primary circular reactionsc.Secondary circular reactionsd.Coordination of secondary schemata

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

PTS:1DIF:Cognitive Level: RememberREF:319TOP:Integrated Process: Nursing Process: AssessmentMSC:Area of Client Needs: Health Promotion and Maintenance

12.A nurse is conducting a teaching session for parents of infants. The nurse explains that which behavior indicates that an infant has developed object permanence?a.Recognizes familiar face, such as motherb.Recognizes familiar object, such as bottlec.Actively searches for a hidden objectd.Secures objects by pulling on a string

ANS:CDuring 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 an object exists even when it is not visible. Between ages 8 and 12 weeks, infants begin to respond differentially to the mother. They cry, smile, vocalize, and show distinct preference for the mother. This preference is one of the stages that influences the attachment process but 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 is part of secondary schemata development.

PTS:1DIF:Cognitive Level: UnderstandREF:319TOP:Integrated Process: Teaching/LearningMSC:Area of Client Needs: Health Promotion and Maintenance

13.A parent asks the nurse at what age do most infants begin to fear strangers? The nurse should give which response?a.2 monthsb.4 monthsc.6 monthsd.12 months

ANS:CBetween 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 unfamiliar people. At 2 months, infants are 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 child does not fear strangers at this age.


14.The nurse is interviewing the father of a 10-month-old infant. She is playing on the floor when she notices an electric 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 the infant:a.is old enough to understand the word no.b.is too young to understand the word no.c.should already know that electric outlets are dangerous.d.will learn safety issues better if she is spanked.

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


15.A 4-month-old was born at 35 weeks of 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.the infants behavior is suggestive of failure to bond completely with her parents.d.the infants difficult temperament is the result of painful experiences in the neonatal period.

ANS:AInfant 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. The infants temperament has been created by both biologic and environmental factors. The nurse should provide guidance in parenting techniques that are best suited to the infants temperament.


16.Which information could be given to the parents of a 12-month-old child regarding appropriate play activities?a.Give large push-pull toys for kinetic 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:AThe 12-month-old child is able to pull to standing and walk holding on or independently. Appropriate toys for a child this age include large 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:1DIF:Cognitive Level: ApplyREF:322TOP:Integrated Process: Teaching/LearningMSC:Area of Client Needs: Health Promotion and Maintenance: Growth and Development

17.The nurse is discussing development and play activities with the parent of a 2-month-old. Recommendations should include giving a first rattle at about which age?a.2 monthsb.4 monthsc.7 monthsd.9 months

ANS:BIt is recommended that a brightly colored toy or rattle be given to the child at age 4 months. Grasping has begun as a deliberate act, and the infant grasps, holds, and begins shaking to hear a noise; 2 months is too young. The infant still has primarily reflex grips; 7 to 9 months is too old for the first rattle. The child should be given toys that provide for further exploration.


18.Which is an appropriate play activity for a 7-month-old infant to encourage visual stimulation?a.Playing peek-a-boob.Playing pat-a-cakec.Imitating animal soundsd.Showing how to clap hands

ANS:ABecause object permanence is a new achievement, peek-a-boo is an excellent activity to practice this new skill for visual stimulation. Pat-a-cake and showing how to clap hands will help with kinetic stimulation. Imitating animal sounds will help with auditory stimulation.


19.Which would be the best play activity for a 6-month-old infant to provide tactile stimulation?a.Allow to splash in bath.b.Give various colored blocks.c.Play music box, tapes, or CDs.d.Use infant swing or stroller.

ANS:AThe feel of the water while the infant is splashing will provide tactile stimulation. Various colored blocks would provide visual stimulation for a 4- to 6-month-old infant. Music box, tapes, and CDs provide auditory stimulation. Swings and strollers provide kinesthetic stimulation.

PTS:1DIF:Cognitive Level: ApplyREF:322TOP:Integrated Process: Nursing Process: PlanningMSC:Area of Client Needs: Health Promotion and Maintenance

20.At what age should the nurse expect an infant to begin smiling in response to pleasurable stimuli?a.1 monthb.2 monthsc.3 monthsd.4 months

ANS:BAt 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.


21.At what age does an infant start to recognize familiar faces and objects, such as a feeding bottle?a.1 monthb.2 monthsc.3 monthsd.4 months

ANS:CThe child can recognize familiar objects at approximately age 3 months. For the first 2 months of life, infants watch and observe their surroundings. The 4-month-old infant is able to anticipate feeding after seeing the bottle.


22.A parent asks the nurse when will my infant start to teethe? The nurse responds that the earliest age at which an infant begins teething with eruption of lower central incisors is _____ months.a.4 b.6 c.8 d.12

ANS:BTeething usually begins at age 6 months with the eruption of the lower central incisors; 4 months is too early for teething. By age 8 months, the infant has the upper and lower central incisors. At age 12 months, the infant has six to eight deciduous teeth.


23.The nurse is guiding parents in selecting a daycare facility for their infant. Which is especially important to consider when making the selection?a.Health practices of facilityb.Structured learning environmentc.Socioeconomic status of childrend.Cultural similarities of children

ANS:AHealth practices should be most important. With the need for diaper changes and assistance with feeding, young children are at increased risk when hand washing and other hygienic measures are not adhered to. A structured learning environment is not suitable for this age child. The socioeconomic status of children should have little effect on the choice of facility. Cultural similarities of children may be important to the families, but the health care practices of the facility are more important.

PTS:1DIF:Cognitive Level: UnderstandREF:323-234TOP:Integrated Process: Teaching/LearningMSC:Area of Client Needs: Health Promotion and Maintenance

24.Austin, age 6 months, has six teeth. The nurse should recognize that this is:a.normal tooth eruption.b.delayed tooth eruption.c.unusual and dangerous.d.earlier-than-normal tooth eruption.

ANS:DSix months is earlier than expected. Most infants at age 6 months have two teeth. Although unusual, it is not dangerous.


25.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:AThe 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 help to keep the childs foot in the shoe. Inflexible shoes can delay walking and can aggravate in-toeing and out-toeing and impede development of the supportive foot muscles.

PTS:1DIF:Cognitive Level: AnalyzeREF:346TOP:Integrated Process: Teaching/LearningMSC:Area of Client Needs: Health Promotion and Maintenance

26.The nurse should teach parents that which age is safe to give infants whole milk instead of commercial infant formula?a.6 monthsb.9 monthsc.12 monthsd.18 months

ANS:CThe 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.


27.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:CFor 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. 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:1DIF:Cognitive Level: ApplyREF:327-328TOP:Integrated Process: Teaching/LearningMSC:Area of Client Needs: Health Promotion and Maintenance

28.What is the best age for solid food to be introduced into the infants diet?a.2 to 3 monthsb.4 to 6 monthsc.When birth weight has tripledd.When tooth eruption has started

ANS:BPhysiologically and developmentally, the 4- to 6-month-old infant 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; 2 to 3 months is too young. The extrusion reflex is strong, and the child will push food out with the tongue. No research indicates that the addition of solid food to a bottle has any benefit. Infant birth weight doubles at 1 year. Solid foods can be started earlier. Tooth eruption can facilitate biting and chewing; most infant foods do not require this ability.

PTS:1DIF:Cognitive Level: UnderstandREF:327TOP:Integrated Process: Nursing Process: PlanningMSC:Area of Client Needs: Health Promotion and Maintenance

29.Which information should the nurse give a mother regarding the introduction of solid foods during infancy?a.Solid foods should not be introduced until 8 to 10 months, when the extrusion reflex begins to disappear.b.Foods should be introduced one at a time, at intervals of 4 to 7 days.c.Solid foods can be mixed in a bottle to make the transition easier for the infant.d.Fruits and vegetables should be introduced into the diet first.

ANS:BOne food item is introduced at intervals of 4 to 7 days to allow the identification of food allergies. Solid foods can be introduced earlier. The extrusion reflex usually disappears by age 6 months. Mixing solid foods in a bottle has no effect on the transition to solid food. Iron-fortified cereal should be the first solid food introduced into the infants diet.

PTS:1DIF:Cognitive Level: ApplyREF:327-328TOP:Integrated Process: Teaching/LearningMSC:Area of Client Needs: Health Promotion and Maintenance

30.The parents of a 4-month-old infant tell the nurse that they are getting a microwave oven and will be able to heat the babys formula faster. What should the nurse recommend?a.Never heat a bottle in a microwave oven.b.Heat only 10 ounces or more.c.Always leave bottle top uncovered to allow heat to escape.d.Shake bottle vigorously for at least 30 seconds after heating.

ANS:ABottles cannot be heated safely in microwave ovens even if safe guidelines are followed and regardless of the amount to be heated due to uneven heating and possible burns.


31.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 which statement?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:DCo-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 under way; no evidence at this time supports or condemns the practice for safety reasons. Co-sleeping is a cultural practice. One year 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.


32.The parent of a 2-week-old infant, exclusively breastfed, asks the nurse if fluoride supplements are needed. The nurses best response should be: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 4 months.d.She can have infant cereal mixed with fluoridated water instead of supplements.

ANS:CFluoride supplementation is recommended by the American Academy of Pediatrics beginning at age 4 months if the child is not drinking adequate amounts of fluoridated water. The amount of water that is ingested and the amount of fluoride in the water are taken into account when supplementation is being considered.


33.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:DThe 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.


34.A mother tells the nurse that she does not 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, EMLA, can be applied before injections are given.

ANS:DSeveral topical anesthetic agents can be used to minimize the discomfort associated with immunization injections. These include EMLA (eutectic mixture of local anesthetic) and vapor coolant sprays. Pain associated with many procedures can be prevented and 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 feel 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.


35.The parents of a 12-month-old child ask the nurse whether the child can eat hot dogs. The nurses reply should be based on which statement?a.Child is too young to digest hot dogs.b.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:DHot 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.

PTS:1DIF:Cognitive Level: ApplyREF:347TOP:Integrated Process: Teaching/LearningMSC:Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control (Injury Prevention)

36.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 with airbag on passenger side.d.rear facing in front seat if an air bag is on the passenger side.

ANS:BThe rear-facing car seat provides the best protection for an infants disproportionately heavy head and weak neck. The middle of the back seat is the safest position for the child. The infant must be rear facing to protect the head and neck in the event of an accident. Severe injuries and deaths in children have occurred from air bags deploying on impact in the front passenger seat.

PTS:1DIF:Cognitive Level: UnderstandREF:344TOP:Integrated Process: Teaching/LearningMSC:Area of Client Needs: Safe and Effective Care Environment

37.Which figure depicts an expected developmental milestone for a 7-month-old infant? a.

c.

b.

d.

ANS:ABy 6 to 7 months of age, infants are able to bear all their weight on their legs with assistance. Infants can stand holding on to furniture at 9 months. While standing, the infant takes a deliberate step at 10 months. Crawling (propelling forward with the belly on the floor) progresses to creeping on hands and knees (with the belly off of the floor) by 9 months.

PTS:1DIF:Cognitive Level: AnalyzeREF:318TOP:Integrated Process: Nursing Process: EvaluationMSC:Area of Client Needs: Health Promotion and Maintenance

MULTIPLE RESPONSE

1.The nurse is teaching parents about appropriate pacifier selection. Which characteristics should the pacifier have? (Select all that apply.)a.Easily grasped handleb.One-piece constructionc.Ribbon or string to secure to clothingd.Soft, pliable materiale.Sturdy, flexible material

ANS:A, B, EA 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. If the pacifier is too pliable, it may be aspirated. No ribbon or string should be attached. This poses additional risks.

PTS:1DIF:Cognitive Level: ApplyREF:345 | 347TOP:Integrated Process: Teaching/LearningMSC:Area of Client Needs: Safe and Effective Care Environment

2.In terms of gross motor development, which should 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.f.Adjust posture to reach an object.

ANS:A, BRolling from abdomen and to back and placing the feet in the mouth when supine are 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. The 8-month-old infant adjusts posture to reach an object.


3.A nurse is teaching a parent about administration of iron supplements to a 7-month-old infant. Which should the nurse include in the teaching session? (Select all that apply.)a.Administer the iron supplement with a dropper toward the side and to the back of the mouthb.Administer the iron supplement with feedings.c.Your infants stools may look tarry green.d.Your infant may have some diarrhea initially.e.Follow the iron supplement with 4 ounces of juice.

ANS:A, C, ELiquid iron supplements may stain the teeth; therefore, administer them with a dropper toward the back of the mouth (side). Ideally, iron supplements should be administered between meals for greater absorption. Avoid administration of liquid iron supplements with whole cows milk or milk products because they bind free iron and prevent absorption. Educate parents that iron supplements will turn stools black or tarry green. Iron supplements may cause transient constipation, not diarrhea. In older children, follow liquid iron supplement with a citrus fruit or juice drink (no more than 3 to 4 oz).


4.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, pertussis (DTaP)d.Varicellae.Haemophilus influenzae type b (HIB)f.Inactivated poliovirus (IPV)

ANS:B, C, E, FRecommended immunization schedule for a 4-month-old, up to date on immunizations, would be to administer the rotavirus (RV), diphtheria, tetanus, pertussis (DTaP), Haemophilus influenza type b (HIB), and inactivated poliovirus (IPV) vaccinations. The measles, mumps, and rubella (MMR) and varicella would not be administered until the child is at least 1 year of age.

PTS:1DIF:Cognitive Level: ApplyREF:331TOP:Integrated Process: Nursing Process: ImplementationMSC:Area of Client Needs: Health Promotion and Maintenance

5.A nurse is preparing to administer immunizations to a 6-month-old infant. Which interventions should the nurse implement to minimize local reaction and reduce pain? (Select all that apply.)a.Select a needle of adequate length (1 inch).b.Inject into the deltoid muscle.c.Apply a vapocoolant spray directly to the skin, 15 seconds before administration.d.Apply a topical anesthetic LMX4 (4% lidocaine) 10 minutes before administration.

ANS:A, C, DTo minimize local reaction and reduce pain when administering an immunization, select a needle of adequate length (25 mm [1 inch] in infants) to deposit the antigen deep in the muscle mass. Apply a vapocoolant spray (e.g., ethyl chloride or Fluori-Methane) directly to the skin or to a cotton ball, which is placed on the skin for 15 seconds immediately before the injection. Inject into the vastus lateralis or ventrogluteal muscle; the deltoid may be used in children 18 months of age and older. Apply the topical anesthetic LMX4 (4% lidocaine) to the injection site 30 minutes before the injection. Ten minutes does not allow the anesthetic to be effective.

PTS:1DIF:Cognitive Level: ApplyREF:340TOP:Integrated Process: Nursing Process: ImplementationMSC:Area of Client Needs: Health Promotion and Maintenance

6.A nurse is teaching a parent about introduction of solid foods into an infants diet. Which should the nurse include in the teaching session? (Select all that apply.)a.Solid food introduction can be started at 2 months of age.b.Rice cereal is introduced first.c.Begin the introduction of solid foods by mixing with formula in the bottle.d.Introduce egg white in small quantities (1 tsp) toward the end of the first year.e.Introduce one food at a time, usually at interval of 4 to 7 days.

ANS:B, D, ERice cereal, because of its low allergenic potential, is the first solid food introduced to an infant at 4 to 6 months of age. Introduce one food at a time, usually at intervals of 4 to 7 days, to identify food allergies. Introduce egg white in small quantities (1 tsp) toward the end of the first year to detect an allergy. Solid food introduction should be started at 4 to 6 months of age. Never introduce foods by mixing them with the formula in a bottle.


ESSAY

1.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. Provide answer using lowercase letters separated by commas (e.g., a, b, c, d, e).a. Voluntary palmar graspb. Reflex palmar graspc. Puts objects into a containerd. Neat pincer graspe. Builds a tower of two blocks, but fails

ANS:b, a, d, c, eGrasping 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 but fail.

PTS:1DIF:Cognitive Level: AnalyzeREF:315TOP:Integrated Process: Nursing Process: EvaluationMSC:Area of Client Needs: Health Promotion and Maintenance

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