Question 1

The nurse is working with first-time parents.Which of these activities will the nurse suggest to encourage the development of good muscle tone?

Accepted Answer

Surrounding the infant with toys and other stimulating items encourages motor movement and helps develop good muscle tone.

Question 2

A nurse is assessing an 11-month-old infant,and notes that the infant's height and weight are at the 5th percentile on the growth chart.Family history reveals that the two siblings are at the 50th percentile for height and at the 75th percentile for weight.Psychosocial history reveals that the parents are separated and are planning to divorce.Which of these nursing diagnoses takes priority?

Accepted Answer

The priority nursing diagnosis in this case is "Alteration in growth pattern related to parental anxiety." This is because the infant's height and weight are significantly below the average for their age and family history shows that the siblings are at a higher percentile for height and weight. The parents' separation and upcoming divorce may be contributing to their anxiety, which can affect their ability to provide adequate care to the infant. It is important for the nurse to address parental anxiety and provide support to help the parents cope with their situation in order to ensure the infant receives appropriate care and growth opportunities. The other options are not as relevant in this case.

Question 3

A nurse assesses the height and weight measurements on an infant and documents these measurements at the 75th percentile.The nurse notes that the measurements 2 months ago were at the 25th percentile.How should the nurse interpret these data?

Accepted Answer

The infant has gained a significant amount of weight, as their measurements have increased from the 25th percentile to the 75th percentile over a two month period. This indicates that the infant is growing as expected and is gaining an appropriate amount of weight.

Question 4

During a health supervision visit,the nurse is attempting to develop a partnering relationship with the child and family.Initially,the nurse should:

Accepted Answer

To develop a partnering relationship with the child and family, it's important to engage in a collaborative process. Discussing with the family a plan to address the child's health needs involves listening to their concerns, understanding their situation, and working together to create a plan that meets the child's needs. This approach fosters trust and partnership.

Question 5

A nurse says to the mother of a 6-month-old infant,"Does the baby sit without assistance,and is the baby crawling?" Which process is the nurse using in this interaction?

Accepted Answer

The nurse is using developmental surveillance to assess the baby's milestones and ensure healthy development. Health promotion and health maintenance focus on ways to prevent illness and maintain wellness, while disease surveillance monitors and tracks the occurrence of specific diseases or conditions.

Question 6

Which observation in a health supervision visit leads nurse to have concerns about the infant's mental health?

Accepted Answer

Avoidance of eye contact can be a red flag for early signs of autism spectrum disorder or other developmental delays. The other options do not directly relate to concerns about the infant's mental health.

Question 7

A parent says to a nurse,"How do you know when my baby needs these screening tests the doctor just mentioned?" Which response should the nurse make to the parent?

Accepted Answer

Screening tests are typically performed at specific ages when a child is most likely to develop a condition, such as hearing and vision tests at birth and developmental screenings at 9 months, 18 months, and 2 years old. The nurse should explain this to the parent to help them understand the rationale behind the screening tests.

Question 8

An infant is growing slowly,and the weight on the growth chart has remained at the 22 standard deviation (22 SD).Which of these interventions takes priority?

Accepted Answer

As the infant's slow growth is likely due to inadequate caloric intake, it is important to first assess the infant's recent intake to identify any potential issues with feeding or formula preparation. Once these issues have been addressed, if the infant's growth continues to be concerning, additional interventions may be necessary. Questioning the mother about development milestones and instructing the family about appropriate dietary intake are also important interventions, but these should be done after assessing the immediate issue of caloric intake. Reporting the case to Child Protective Services is not necessary based on the information given.

Question 9

A new mother has been taught that her infant needs to be seen in the pediatrician's office for the initial health care visit.The mother asks the nurse what the purpose of this visit will be.The nurse explains that during this initial visit,the nurse will: (Select all that apply. )

Accepted Answer

The initial visit to a pediatrician's office often includes discussing policies related to the provision of care (A), evaluating the parents' understanding of the services offered (B), and assessing the compatibility of personalities between the parents and the healthcare provider (C). These aspects are crucial for establishing a good foundation for ongoing healthcare for the infant. Determining whether the parents are child abusers (D) and whether they will make their infant obese (E) are not standard objectives of an initial health care visit.

Question 10

The clinic administrator has asked each nurse to classify the nursing activities as a beginning step of clinic reorganization.Which of these strategies can be classified as health promotion and health maintenance? Select all that apply.

Accepted Answer

- A) Administering the flu vaccine is a preventive measure to protect infants from influenza, promoting their health.- B) Creating feeding schedules for infants with new parents helps in ensuring proper nutrition, which is crucial for the infant's growth and development, thus maintaining their health.- C) Instructing adolescents on dental flossing promotes oral health by preventing dental issues.

Question 11

The nurse is assessing a small-for-gestational-age newborn who had an older sibling who died of sudden infant death syndrome.Knowing this,the nurse must include which in the plan of care for the newborn?

Accepted Answer

The nurse should encourage the parents to place the infant in a crib with a tight-fitting, firm mattress in order to promote safe sleep and reduce the risk of sudden infant death syndrome. Placing the infant on their abdomen to sleep and using a soft mattress with extra blankets are both practices that increase the risk of SIDS. Co-sleeping with the infant may also increase the risk of SIDS.

Question 12

A mother who is bottle-feeding her newborn asks to be discharged 24 post-delivery because she also has twin 2-year-olds at home.The nurse should schedule the office visit for the newborn:

Accepted Answer

It is recommended that newborns be seen by a healthcare provider within 48 hours of discharge. This allows for assessment of the newborn's feeding and weight gain, as well as monitoring for any potential complications. It is especially important in this case as the mother is bottle-feeding and may need assistance or guidance in ensuring proper feeding and monitoring of the baby's intake.

Question 13

While interviewing the parents of a 2-year-old female,the nurse notes that the mother is pregnant.At the end of the visit,the nurse decides to give a new pamphlet to the parents about car seat usage for newborns.This action is an example of:

Accepted Answer

Providing a pamphlet about car seat usage for newborns is an example of primary preventative health maintenance, as it is aimed at preventing potential health problems before they occur. This action encourages the parents to take preventive measures and promotes the child's safety.

Question 14

Parents are in the physician's office with their infant for a 1-month checkup.Which of the following immunizations should the nurse ask whether the newborn received in the hospital after birth?

Accepted Answer

Hepatitis B vaccine is typically given to infants before leaving the hospital after birth, so it is important to confirm whether the newborn received the vaccine. Influenza, Rotavirus, and Rubella vaccines are not typically given to newborns in the hospital.

Question 15

A nurse is helping the parents of 2-year-old twins cope with the daily demands of life in an active household.Which of these strategies should the nurse use?

Accepted Answer

Health promotion focuses on teaching individuals and families how to maintain and improve their overall health and well-being. This would be the most appropriate strategy to help the parents of 2-year-old twins cope with the daily demands of their active household. The nurse can provide education on nutrition, exercise, playtime activities, and stress management, among other topics. This approach emphasizes empowerment and prevention rather than simply addressing health concerns as they arise.

Quiz 36: Health Promotion and Maintenance: General Concepts, the Newborn, and the Infant