Chapter 16 - Test Questions

(1)

Chapter 16: The Infant Test Bank

MULTIPLE CHOICE

1. A mother calls the pediatrician’s office because her infant is “colicky.” The helpful measure the nurse would suggest to the parent is to:

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 infant’s 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: p. 395 OBJ: 15 TOP: Colic KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

2. The nurse is aware that the age at which the posterior fontanelle closes is _____ months. a. 2 to 3

b. 3 to 6 c. 6 to 9 d. 9 to 12

ANS: A

The posterior fontanelle closes between 2 and 3 months of age. DIF: Cognitive Level: Knowledge REF: p. 390, Box 16-1

OBJ: 12 TOP: Fontanelle KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 3. The nurse knows that an infant’s birth weight should be tripled by:

a. 9 months. b. 1 year. c. 18 months. d. 2 years.

ANS: B

The infant usually triples his or her birth weight by about 12 months of age. DIF: Cognitive Level: Knowledge REF: p. 394, Box 16-1 OBJ: 2 TOP: Development and Care

(2)

4. The nurse is aware that the earliest age at which an infant is able to sit steadily alone is _____ months. a. 4 b. 5 c. 8 d. 15 ANS: C

The infant can sit alone without support at about 8 months of age. DIF: Cognitive Level: Knowledge REF: p. 392, Table 16-1 OBJ: 12 TOP: Sitting Alone

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 5. The nurse is aware that the earliest age at which the infant should be able to walk

independently is _____ months. a. 8 to 10 b. 12 to 15 c. 15 to 18 d. 18 to 21 ANS: B

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

DIF: Cognitive Level: Knowledge REF: p. 394, Table 16-1 OBJ: 12 TOP: Walk Independently

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

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

a. 5 months. b. 9 months. c. 1 year. d. 2 years.

ANS: A

The infant can usually drink from a cup when it is offered at about 5 months. DIF: Cognitive Level: Comprehension REF: p. 393, Table 16-1, Fig 16-9 OBJ: 11 TOP: Drink from Cup

(3)

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 7. The nurse would expect a 4-month-old to be able to:

a. hold a cup.

b. stand with assistance. c. lift head and shoulders. d. sit with back straight.

ANS: C

Because development is cephalocaudal, of these choices, 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: Analysis REF: p. 391, Table 16-1 OBJ: 2 TOP: Development and Care

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

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: p. 391, Table 16-1 OBJ: 2 TOP: Head Control

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. The nurse weighing the infant today would expect her weight to be at least _____ pounds.

a. 12 b. 16 c. 20 d. 24

ANS: B

Birth weight is usually doubled by 6 months of age.

(4)

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 10. The nurse would advise a parent when introducing solid foods to:

a. begin with one tablespoon of 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: p. 401 OBJ: 5 TOP: Solid Food KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 11. When talking with a parent about tooth eruption, the nurse explains that the first

deciduous teeth to erupt are the _____ incisors. a. lower central

b. upper central c. lower lateral d. upper lateral

ANS: A

The first teeth to erupt, usually at about 7 months, are the lower central incisors. DIF: Cognitive Level: Knowledge REF: p. 392, Table 16-1

OBJ: 12 TOP: Development and Care KEY: Nursing Process Step: Implementation

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

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: p. 393, Table 16-1 OBJ: 2 TOP: Development and Care

(5)

13. The statement made by a parent that indicates correct understanding of infant feeding is: a. “I’ve been mixing rice cereal and formula in the baby’s bottle.”

b. “I switched the baby to low-fat milk at 9 months.” c. “The baby really likes little pieces of chocolate.”

d. “I give the baby any new foods before he takes his bottle.” ANS: D

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

DIF: Cognitive Level: Analysis REF: p. 402, Nursing Tip OBJ: 5 TOP: Nutrition Counseling

KEY: Nursing Process Step: Evaluation

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

a. keep the infant’s room well lit. b. rub the infant’s 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: p. 396 OBJ: 4 TOP: Lethargy KEY: Nursing Process Step: Implementation

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

a. “I put covers on all of the electrical outlets.” b. “In the car, she rides in a front-facing car seat.” c. “There are locks on all of the cabinets in the house.” d. “I have a gate at the top and bottom of the stairs.”

ANS: B

A rear-facing infant car seat should be used for infants younger than 1 year of age. DIF: Cognitive Level: Analysis REF: p. 403 OBJ: 13 TOP: Infant Safety KEY: Nursing Process Step: Evaluation

(6)

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: Analysis REF: p. 394, Table 16-1

OBJ: 2 TOP: General Characteristics KEY: Nursing Process Step: Assessment

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

a. use commercial diaper wipes to clean the area. b. apply a protective ointment on the area. c. change the infant’s 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: p. 396 OBJ: 4 TOP: Diaper Rash KEY: Nursing Process Step: Implementation

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

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 him. d. change the infant’s 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: p. 395 OBJ: 11 TOP: Infant Care KEY: Nursing Process Step: Implementation

(7)

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

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: p. 404, Table 16-4

OBJ: 2 TOP: Infant Safety KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

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

a. “I put the baby in my bed until she falls asleep, then I put her in her crib.” b. “I let the baby skip an afternoon nap so she will fall asleep earlier.” c. “I put the pacifier in the crib so she can find it when she wakes up.” d. “I rock the baby back to sleep if she wakes up at night.”

ANS: C

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

DIF: Cognitive Level: Analysis REF: p. 396 OBJ: 18

TOP: Sleep Patterns KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 21. The nurse demonstrates the parachute reflex by:

a. lifting the infant high in the air above her head. b. holding 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: p. 387, Figure 16-3

OBJ: 2 TOP: Parachute Reflex KEY: Nursing Process Step: Implementation

22. The nurse explains that by the age of 6 months an iron-rich formula should be offered because the infant has:

(8)

d. need of the iron to support dentition.

ANS: C DIF: Cognitive Level: Comprehension REF: p. 404, Table 16-4 OBJ: 5 TOP: Iron Supplement

KEY: Nursing Process Step: Implementation

MULTIPLE RESPONSE

23. 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: Application REF: p. 386 OBJ: 2 TOP: Hunger KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 24. The nurse outlines what principles of discipline for an infant? Select all that apply. a. Firmly say “No.”

b. Distract child to another activity. c. Bribe the child with a sweet treat. d. Remain consistent.

e. Ignore child until behavior improves.

ANS: A, B, D DIF: Cognitive Level: Application REF: p. 388

OBJ: 3 TOP: Discipline KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

25. 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.

(9)

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: p. 403 OBJ: 17 TOP: Fall Prevention KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk

26. 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: Analysis REF: p. 399, Table 16-2, Figure 16-4 OBJ: 2 TOP: Feeding Skills

27. The nurse reminds the parents that their 2-month-old should receive three immunizations for which illnesses.

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: Application REF: p. 390, Box 16-1

OBJ: 4 TOP: Immunizations KEY: Nursing Process Step: Implementation

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

COMPLETION

28. 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 ___________.

(10)

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: p. 389, Figure 16-3

OBJ: 2 TOP: Creeping KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

29. 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: p. 396 OBJ: 14

TOP: Positions for Sleep KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk

OTHER

30. The nurse explains that an infant’s prehensile development is progressive and logical. Arrange the development in the order from the simplest to the most complex.

a. Hands held open most of the time

b. Grasps with thumb on one side and three fingers on the other c. Picks up toy with squeeze action

d. Thumb and forefinger hold object e. Hands held closed most of the time ANS:

E, A, C, B, D

The development advances from the newborn’s 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: pp. 387-388, Figure 16-3 OBJ: 2 TOP: Prehensile Development

KEY: Nursing Process Step: Implementation