Infant

Question 1

A 6-month-old male is at his well-child checkup. The nurse weighs him, and his mother asks if his weight is normal for his age. The nurse’s best response is:

1. “At 6 months his weight should be approximately three times his birth weight.”
2. “Each child gains weight at his or her own pace.”
3. “At 6 months his weight should be approximately twice his birth weight.”
4. “At 6 months a child should weigh about 10 lb more than his or her birth weight.”

Answer 1

3. Infants should double their birth weight by 4 to 6 months of age.

Question 2

2. How can the nurse best facilitate the trust relationship between infant and parents while the infant is hospitalized? The nurse should:
3. Encourage the parents to remain at their child’s bedside as much as possible.
4. Keep parents informed about all aspects of their child’s condition.
5. Encourage the parents to hold their child as much as possible.
6. Advise the parents to participate actively in their child’s care

Answer 2

3. Having parents hold their child while in the hospital is an excellent means of building the trust relationship. Infants are most secure when they are being held, patted, and spoken to.

Question 3

3. The nurse is going to give a 6-month-old a dose of Rocephin IM. What must the nurse do when the 1.5-mL dose arrives from the pharmacy?
4. Administer the injection into the deltoid muscle.
5. Divide the dose into two injections.
6. Administer the injection into the dorsogluteal muscle. 4. Give dose as a single injection into the vastus lateralis muscle.

Answer 3

2. A nurse should not deliver more than 1 mL per IM injection to a 6-month-old.

Question 4

4. Which statement by an infant’s mother leads the nurse to believe that she needs further education about the nutritional needs of a 6-month-old?
5. “I will continue to breastfeed my son and will give him rice cereal three times a day.”
6. “I will start my son on fruits and gradually introduce vegetables.”
7. “I will start my son on carrots and will introduce one new vegetable every few days.”
8. “I will not give my son any more than 8 ounces of baby juice per day.”

Answer 4

2. Infants should be started on vegetables prior to fruits. The sweetness of fruits may inhibit infants from taking vegetables.

Question 5

5. Which statement accurately describes the best method for assessing a 12-month-old?
6. The nurse should assess the child on the examining table.
7. The nurse should assess the child in a head-to-toe sequence.
8. The nurse should have the child’s mother assist in holding her down.
9. The nurse should assess the child while she is in her mother’s lap.

Answer 5

4. Infants are most secure when in proximity to the parent. The parent’s lap is an excellent place to assess the child.

Question 6

6. The nurse is instructing a new breastfeeding mother in the need to provide her premature infant with an adequate source of iron in her diet. Which statement reflects a need for further education of the new mother?
7. “I will use only breast milk or an iron-fortified formula as a source of milk for my baby until she is at least 12 months old.”
8. “My baby will need to have iron supplements introduced when she is 4 months old.”
9. “I will need to add iron supplements to my baby’s diet when she is 2 months old.”
10. “When my baby begins to eat solid foods, I should introduce iron-fortified cereals to her diet.”

Answer 6

3. Premature infants have iron stores from the mother that last approximately 2 months, so it is important to introduce an iron supplement by 2 months of age. Full-term infants have iron stores that last approximately 4 to 6 months

Question 7

7. A first-time mother brings in her 5-day-old baby for a well-child visit. The nurse weighs the infant and reports a weight of 7 lb 5 oz to the mother. The mother looks concerned and tells the nurse that her baby weighed 7 lb 10 oz when she was discharged 4 days ago. The nurse’s best response to the mother is:
8. “I will let the doctor know, and he will talk with you about possible causes of your infant’s weight loss.”
9. “Al weight loss of a few ounces is common among newborns, especially for breastfeeding mothers.”
10. “I can tell you are a first-time mother. Don’t worry; we will find out why she is losing weight.”
11. “Maybe she isn’t getting enough milk. How often are you breastfeeding her?”

Answer 7

2. Newborns can lose up to 10% of their birth weight without concern but should regain their birth weight by 2 weeks of age

Question 8

Which toy is the best choice for a 12-month-old?

1. Baby doll.
2. Musical rattle.
3. Board book.
4. Colorful beads.

Answer 8

2. A musical rattle is the perfect toy for this child. Infants have short attention spans and enjoy auditory and visual stimulation.

Question 9

9. The parents of a newborn are asking the nurse how to use the infant car seat and where it should be placed in their vehicle. Which is the next most appropriate action by the nurse?
10. Give the parents a pamphlet explaining how to install the car seat.
11. Accompany the parents to the car, and show them how to install the car seat.
12. Contact the hospital’s car-seat safety officer, and ask the officer to accompany the parents to the car for car-seat installation.
13. Show the parents a video on car-seat installation and safety, and ask if they are comfortable with the information.

Answer 9

3. The car-seat safety officer is the best choice, as that individual would have the needed information and certification to help the family

Question 10

10. The mother of a newborn asks the nurse when the infant will receive the first hepatitis B immunization. Which is the nurse’s best response?
11. “Babies receive the hepatitis B vaccine only if their mother is hepatitis B–positive.”
12. “The first dose of the hepatitis B vaccine will be given prior to discharge today.”
13. “The first dose of hepatitis B vaccine is given at 1 year of age.”
14. “Babies receive their first hepatitis B vaccine at 6 months of age.”

Answer 10

2. The first dose of hepatitis B vaccine is recommended between birth and 2 months. In most hospitals, newborns are given the vaccine prior to discharge.

Question 11

11. Which finding would the nurse consider abnormal when performing a physical assessment on a 6-month-old?
12. Posterior fontanel is open.
13. Anterior fontanel is open.
14. Beginning signs of tooth eruption.
15. Able to track and follow objects.

Answer 11

1. The posterior fontanel should close between 6 and 8 weeks of age.

Question 12

12. A mother requests that her child receive the varicella vaccine at the 9-month well-child checkup. The nurse tells the mother that:
13. Children who are vaccinated will likely develop a mild case of the disease.
14. The vaccine cannot be given at that visit.
15. The vaccine will be administered after the physician examines the child.
16. A booster vaccination will be needed at 18 months of age.

Answer 12

2. The nurse should not give the vaccine. The varicella vaccine is not usually administered prior to 1 year of age.

Question 13

What should parents understand is one of the most common causes of injury and death for a 7-month-old infant?

1. Poisoning.
2. Child abuse.
3. Aspiration.
4. Dog bites.

Answer 13

3. Aspiration is a common cause of injury and death among children of this age. These children often find small objects lying on the floor and place them in their mouths. Older siblings are often responsible for leaving small objects around.

Question 14

14. An 8-day-old was admitted to the hospital with vomiting and dehydration. The newborn’s heart rate is 170, respiratory rate is 44, blood pressure is 85/52, and temperature is 99°F (37.2°C). What is the nurse’s best response to the parents who ask if the vital signs are normal?
15. “The blood pressure is elevated, but the other vital signs are within normal limits.”
16. “The temperature is elevated, but the other vital signs are within normal limits.”
17. “The respiratory rate is elevated, but the other vital signs are within normal limits.”
18. “The heart rate is elevated, but the other vital signs are within normal limits.”

Answer 14

4. A normal heart rate for a child from birth to 1 month is 90 to 160.

Question 15

15. The mother of an 11-month-old with iron deficiency anemia tells the nurse that her infant is currently taking iron and a multivitamin. Which statement made by the mother should be of concern to the nurse?
16. “I give the iron and multivitamin at the same time each morning.”
17. “I give the iron and multivitamin in the morning 6-oz bottle.”
18. “I give the iron and multivitamin 2 hours before I feed the morning bottle.”
19. “I give the iron and multivitamin in oral syringes toward the back of the cheek.”

Answer 15

2. Medications should never be mixed in a large amount of food or formula because the parent cannot be sure that the child will take the entire feeding. Formula decreases the absorption of iron.

Question 16

16. The nurse is using the FLACC scale to rate the pain level in a 9-month-old. Which is the nurse’s best response to the father’s question of what the FLACC scale is?
17. “It estimates a child’s level of pain utilizing vital sign information.”
18. “It estimates a child’s level of pain based on parents’ perception.”
19. “It estimates a child’s level of pain utilizing behavioral and physical responses.”
20. “It estimates a child’s level of pain utilizing a numeric scale from 0 to 5.”

Answer 16

3. The FLACC scale utilizes behavioral and physical responses of the child to measure the child’s level of pain. The scale utilizes facial expression, leg position, activity, intensity of cry, and level of consolability.

Question 17

17. A 12-month-old boy weighed 8 lb 2 oz at birth. Understanding developmental milestones, what should the nurse caring for the child expect the current weight to be?
18. 16 lb 4 oz
19. 20 lb 5 oz
20. 24 lb 6 oz
21. 32 lb 8 oz

Answer 17

3. Children should triple their birth weight by 12 months of age.

Question 18

18. The nurse is assessing the pain level in an infant who just had surgery. The infant’s parent asks which vital sign changes are expected in a child experiencing pain. The nurse’s best response is:
19. “We expect to see a child’s heart rate decrease and respiratory rate increase.”
20. “We expect to see a child’s heart rate and blood pressure decrease.”
21. “We expect to see a child’s heart rate and blood pressure increase.”
22. “We expect to see a child’s heart rate increase and blood pressure decrease.”

Answer 18

3. When a child is experiencing pain, the normal physiological response is for the heart rate, respiratory rate, and blood pressure to increase.