Question 1

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?

A)The infant is not gaining enough weight.
B)The infant has gained a significant amount of weight.
C)These measurements most likely are inaccurate.
D)The previous measurements were most likely inaccurate.

Accepted Answer

The infant's measurements at the 75th percentile indicate significant weight gain, which is a positive change. This indicates that the infant is growing appropriately.

Question 2

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?

A)Encourage the parents to sleep with the infant for close observation.
B)Encourage the parents to place the infant on his abdomen to sleep.
C)Encourage the parents to place the infant in a crib with a tight-fitting, firm mattress.
D)Encourage the parents to place the infant in a crib with a soft mattress with extra blankets.

Accepted Answer

Placing the infant in a crib with a tight-fitting, firm mattress is recommended to reduce the risk of sudden infant death syndrome (SIDS). The other options, such as placing the infant on their abdomen or sleeping with the infant, are not recommended and may increase the risk of SIDS.

Question 3

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:&#10;A)Within 2 weeks of discharge.&#10;B)When the infant is 1 month old.&#10;C)Within 1 week of discharge.&#10;D)Within 48 hours of discharge.

Accepted Answer

Newborns should have their first office visit within 48 hours of discharge, especially if discharged less than 48 hours after birth, to monitor for jaundice, feeding issues, and weight loss.

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:&#10;A)Tell the family what the child should be doing physically for the age level.&#10;B)Tell the family that the physician will Answer : any questions they might have related to their child's growth and development.&#10;C)Set goals for the family related to the child's health.&#10;D)Discuss with the family a plan to address the child's health needs.

Accepted Answer

The best choice is to discuss with the family a plan to address the child's health needs. This allows the nurse to establish a partnership with the child and family, and involve them in the decision-making process. Providing information about physical development and setting goals may be important, but it should be done collaboratively with the child and family. It is not appropriate to defer all questions to the physician, as the nurse is also a valuable resource for information and guidance.

Question 5

The nurse is working with first-time parents. Which of these activities will the nurse suggest to encourage the development of good muscle tone?&#10;A)Placing the infant in an infant seat rather than lying down in a crib&#10;B)Surrounding the infant with toys and other stimulating items to encourage motor movement&#10;C)Swaddling the infant&#10;D)Putting the infant to bed each night at 8 p.m., even if the infant protests with crying

Accepted Answer

Surrounding the infant with toys and other stimulating items encourages motor movement, which helps in developing good muscle tone.

Question 6

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?

A)Alteration in growth pattern secondary to familial short stature
B)Alteration in growth pattern related to parental anxiety
C)Nutritional intake: excessive secondary to maternal feeding patterns
D)At risk for constitutional growth delay as related to decreased appetite

Accepted Answer

The priority nursing diagnosis in this scenario is related to parental anxiety affecting the infant's growth. This is because anxiety and stress can affect the quality and quantity of nutrition the infant receives, which can lead to growth impairment. It is important for the nurse to assess and address the parents' anxiety and provide resources for coping with the divorce. Although the infant's height and weight are below the 50th percentile, this alone does not necessarily indicate a growth problem.Nutritional intake cannot be identified as excessive without further assessment. Constitutional growth delay would be an unlikely diagnosis at this age.

Question 7

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?&#10;A)Influenza&#10;B)Hepatitis B&#10;C)Rubella&#10;D)Rotavirus

Accepted Answer

Hepatitis B is typically given to newborns in the hospital shortly after birth to prevent transmission of the virus from an infected mother. Influenza, rubella, and rotavirus immunizations are not typically given until the child is older.

Question 8

A nurse says to the mother of a 6-month-old infant, &#34;Does the baby sit without assistance, and is the baby crawling?&#34; Which process is the nurse using in this interaction?&#10;A)Health promotion&#10;B)Developmental surveillance&#10;C)Health maintenance&#10;D)Disease surveillance

Accepted Answer

The nurse is using developmental surveillance by asking about the baby's developmental milestones. This process involves observing and assessing a child's developmental progress and looking for any delays or concerns. It helps to identify any issues early on and ensures appropriate interventions and referrals are made if necessary.

Question 9

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:

A)Secondary preventative health maintenance.
B)Developmental screening.
C)Tertiary preventative health maintenance.
D)Primary preventative health maintenance.

Accepted Answer

This action is an example of primary preventative health maintenance because the nurse is providing information to prevent a potential injury or health problem (in this case, incorrect car seat usage for a newborn).

Question 10

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.)

A)Determine whether the parents are child abusers.
B)Determine whether the parents' and health care provider's personalities are compatible.
C)Discuss policies related to provision of care.
D)Evaluate the parents' understanding of the services offered.
E)Determine whether the parents will make their infant obese.

Accepted Answer

The answer of A new mother has been taught that...

Question 11

A parent says to a nurse, &#34;How do you know when my baby needs these screening tests the doctor just mentioned?&#34; Which response should the nurse make to the parent?&#10;A)&#34;Screening tests are done in the newborn nursery, and from these results, additional screening tests are ordered throughout the first two years of life.&#34;&#10;B)&#34;Screening tests are done at each office visit.&#34;&#10;C)&#34;Screening tests are most often done when the doctor suspects something is wrong with the child.&#34;&#10;D)&#34;Screening tests are administered at the ages when a child is most likely to develop a condition.&#34;

Accepted Answer

The answer of A parent says to a nurse, &#34;How...

Question 12

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.

A)Instructing adolescents on how to use dental floss
B)Treating a child with a diagnosis of acute otitis media
C)Administering the flu vaccine to infants 6-23 months old
D)Working with new parents to create daily feeding schedules for infants

Accepted Answer

The answer of The clinic administrator has asked each nurse...

Question 13

Which observation in a health supervision visit leads nurse to have concerns about the infant's mental health?&#10;A)The parent swaddles her 1-month-old, who is crying after an immunization.&#10;B)When the nurse reaches for a 9-month-old, the infant grabs her mother and cries.&#10;C)A 9-month-old avoids eye contact with parents and the nurse.&#10;D)A 10-month-old reportedly sleeps about 12 hour total per night.

Accepted Answer

The answer of Which observation in a health supervision visit...

Deck 35: Health Promotion and Maintenance: General Concepts, the Newborn, and the Infant