1. A nurse is providing information to a group of pregnant clients and their
partners about the psychosocial development of an infant. Using
... [Show More] Erikson's
theory of psychosocial development, what should the nurse tell the group about
the infants?
A. Rely on the fact that their needs will be met Correct
B. Need to tolerate a great deal of frustration and discomfort to
develop a healthy personality
C. Must have needs ignored for short periods to develop a
healthy personality
D. Need to experience frustration, so it is best to allow an infant to
cry for a while before meeting his or her needs
Rationale: According to Erikson’s theory of psychosocial development, infants
struggle to establish a sense of basic trust rather than a sense of basic mistrust
in their world, their caregivers, and themselves. If provided with consistent
satisfying experiences that are delivered in a timely manner, infants come to
rely on the fact that their needs are met and that, in turn, they will be able to
tolerate some degree of frustration and discomfort until those needs are met.
This sense of confidence is an early form of trust and provides the foundation
for a healthy personality. Therefore the other options are incorrect.
Test-Taking Strategy: Eliminate the option that contains the closed-ended word
"must." Eliminate the options that are comparable or alike and indicate that
experiencing frustration is necessary. Review: Erikson’s theory of psychosocial
development as it relates to the infant.
Reference:
McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternalchild nursing (4th ed., pp. 74-75). St. Louis: Elsevier.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching and Learning
Content Area: Developmental Stages
Giddens Concepts: Development, Reproduction
HESI Concepts: Developmental, Sexuality/Reproduction
Awarded 1.0 points out of 1.0 possible points.
2. 2.ID: 9476987754
A nurse is weighing a breastfed 6-month-old infant who has been brought to
the pediatrician's office for a scheduled visit. The infant's weight at birth was 6
lb 8 oz (2.9 kg). The nurse notes that the infant now weighs 13 lb (5.9
kg). Which action should the nurse take?A. Tell the mother that the infant's weight is increasing as
expected Correct
B. Tell the mother to decrease the daily number of feedings
because the weight gain is excessive
C. Tell the mother that semisolid foods should not be introduced
until the infant's weight stabilizes
D. Tell the mother that the infant should be switched from breast
milk to formula because the weight gain is inadequate
Rationale: Infants usually double their birth weight by 6 months and triple it by 1
year of age. If the infant is 6 lb 8 oz (2.9 kg), at birth, a weight of 13 lb (5.9 kg)
at 6 months of age is to be expected. Semisolid foods are usually introduced
between 4 and 6 months of age.
Test-Taking Strategy: Focus on the subject in the question, the current weight
of the infant. Recalling that infants double their weight by 6 months of age will
direct you to the correct option. Review: the growth rate of an infant.
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J.
(2013). Maternal-child nursing (4th ed., pp. 488-489). St. Louis: Elsevier.
Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of
nursing. (8th ed., p. 143). St. Louis: Mosby.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Developmental Stages
Giddens Concepts: Development, Nutrition
HESI Concepts: Developmental, Nutrition
Awarded 1.0 points out of 1.0 possible points.
3. 3.ID: 9476997157
A nurse performing a physical assessment of a 12-month-old infant notes that
the infant's head circumference is the same as the chest circumference. Based
on this finding, what should the nurse do?
A. Suspect the presence of hydrocephalus
B. Suggest to the pediatrician that a skull x-ray be performed
C. Tell the mother that the infant is growing faster than expected
D. Document these measurements in the infant's health-care
record Correct
Rationale: The head circumference growth rate during the first year is
approximately 0.4 inch (1 cm) per month. By 10 to 12 months of age, the
infant’s head and chest circumferences are equal. Therefore, suspecting the
presence of hydrocephalus, telling the mother that the infant is growing faster
than expected, and suggesting that a skull x-ray be performed are incorrect.
Test-Taking Strategy: Eliminate the options that are comparable or alike andindicate that the infant has a physiological problem. Review: the expected
growth rate of an infant.
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J.
(2013). Maternal-child nursing (4th ed., p. 69, 489-490). St. Louis: Elsevier.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Implementation
Content Area: Developmental Stages
Giddens Concepts: Clinical Judgment, Development
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Developmental
Awarded 1.0 points out of 1.0 possible points.
4. 4.ID: 9476985787
A new mother asks the nurse, "I was told that my infant received my antibodies
during pregnancy. Does that mean that my infant is protected against
infections?" Which statement should the nurse make in response to the
mother?
A. "Yes, your infant is protected from all infections."
B. "If you breastfeed, your infant is protected from infection."
C. "The transfer of your antibodies protects your infant until the
infant is 12 months old."
D. "The immune system of an infant is immature, and the infant is
at risk for infection." Correct
Rationale: Transplacental transfer of maternal antibodies supplements the
infant’s weak response to infection until approximately 3 to 4 months of age.
Although the infant begins to produce immunoglobulin (Ig) soon after birth, by 1
year of age the infant has only approximately 60% of the adult IgG level, 75%
of the adult IgM level, and 20% of the adult IgA level. Breast milk transmits
additional IgA protection. The activity of T-lymphocytes also increases after
birth. Even though the immune system matures during infancy, maximal
protection against infection is not achieved until early childhood. This
immaturity places the infant at risk for infection.
Test-Taking Strategy: Eliminate the option containing the closed-ended word
"all." Recalling that breastfeeding alone does not protect the infant from
infection will assist you in eliminating the option that suggests breastfeeding
protects the infant. From the remaining options, use the strategy of selecting
the umbrella option to answer correctly. Review: the physiological concepts
related to the maturity of body systems in an infant.
References: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J.
(2013). Maternal-child nursing (4th ed., pp. 477-478). St. Louis: Elsevier.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/Implementation
Content Area: Developmental Stages
Giddens Concepts: Development, Immunity
HESI Concepts: Developmental, Immunity
Awarded 1.0 points out of 1.0 possible points.
5. 5.ID: 9476985720
A nurse is assessing the language development of a 9-month-old infant. Which
developmental milestone does the nurse expect to note in an infant of this age?
A. The infant babbles.
B. The infant says "Mama." Correct
C. The infant smiles and coos.
D. The infant babbles single consonants.
Rationale: An 8- to 9-month-old infant can string vowels and consonants
together. The first words, such as "Mama," "Daddy," "bye-bye," and "baby,"
begin to have meaning. A 1- to 3-month-old infant produces cooing sounds.
Babbling is common in a 3- to 4-month-old. Single-consonant babbling occurs
between 6 and 8 months of age.
Test-Taking Strategy: Focus on the subject, the age of the infant. Recalling the
language development that occurs during infancy will direct you to the correct
option. Remember that an 8- to 9-month-old infant can string vowels and
consonants together. Review: the developmental milestones related to
language development in an infant.
Reference:McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J.
(2013). Maternal-child nursing (4th ed., pp. 94, 112). St. Louis: Elsevier.
Level of Cognitive Ability: Understanding
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Assessment
Content Area: Developmental Stages
Giddens Concepts: Commuication, Development
HESI Concepts: Communication, Developmental
Awarded 1.0 points out of 1.0 possible points.
6. 6.ID: 9476988639
The mother of a 9-month-old infant calls the nurse at the pediatrician's office,
tells the nurse that her infant is teething, and asks what can be done to relieve
the infant's discomfort. What should the nurse instruct the mother to do?
A. Schedule an appointment with a dentist for a dental evaluation
B. Rub the infant's gums with baby aspirin that has been
dissolved in water
C. Obtain an over-the-counter (OTC) topical medication for gumpain reliefD. Give the infant cool liquids or a Popsicle and hard foods such
as dry toast Correct
Rationale: Although sometimes asymptomatic, teething is often signaled by
behavior such as nighttime awakening, daytime restlessness, an increase in
nonnutritive sucking, excess drooling, and temporary loss of appetite. Some
degree of discomfort is normal. It is unnecessary to obtain a dental evaluation,
but a health-care professional should further investigate any incidence of
increased temperature, irritability, ear-tugging, or diarrhea. The nurse may
suggest that the mother provide cool liquids and hard foods such as dry toast,
Popsicles, or a frozen bagel for chewing to relieve discomfort. Hard, cold
teethers and ice wrapped in cloth may also provide comfort for inflamed gums.
OTC medications for gum relief should only be used as directed by the
healthcare provider. Home remedies such as rubbing the gums with aspirin
should be discouraged, but acetaminophen (Tylenol), administered as directed
for the child’s age, can relieve discomfort.
Test-Taking Strategy: Focus on the subject, teething and relieving the infant’s
discomfort. First recall that it is unnecessary to consult with a dentist. Next,
eliminate the options that are comparable or alike and involve administering
medication to the infant. Review: the measures that will relieve the discomfort
of teething.
Reference:McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J.
(2013). Maternal-child nursing (4th ed., p. 105). St. Louis: Elsevier.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Developmental Stages
Giddens Concepts: Comfort, Development
HESI Concepts: Comfort—Pain, Developmental
Awarded 1.0 points out of 1.0 possible points.
7. 7.ID: 9476988697
A nurse is teaching the mother of an 11-month-old infant how to clean the
infant's teeth. What should the nurse tell the mother to do?
A. Use water and a cotton swab and rub the teeth Correct
B. Use diluted fluoride and rub the teeth with a soft washcloth
C. Use a small amount of toothpaste and a soft-bristle toothbrush
D. Dip the infant's pacifier in maple syrup so that the infant will
suck
Rationale: Because the primary teeth are used for chewing until the permanent
teeth erupt and because decay of the primary teeth often results in decay of the
permanent teeth, dental care must be started in infancy. The mother can use
cotton swabs or a soft washcloth to clean the teeth. Appropriate amounts offluoride are necessary for the development of healthy teeth, but infants usually
receive fluoride when formula and cereal are mixed with fluoridated water or
through fluoride supplementation. Toothpaste is not recommended because
infants tend to swallow it, possibly ingesting excessive amounts of fluoride.
Dipping the infant’s pacifier in maple syrup is unacceptable because of the risk
of tooth decay.
Test-Taking Strategy: Focus on the subject, cleaning the teeth. Recalling the
risk associated with tooth decay will help eliminate the option that identifies the
use of maple syrup. To select from the remaining options, noting that the client
in the question is an infant will direct you to the correct option. Review: the
procedure for cleaning teeth in an infant.
Reference:McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J.
(2013). Maternal-child nursing (4th ed., p. 105). St. Louis: Elsevier.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching and Learning
Content Area: Developmental Stages
Giddens Concepts: Client Education, Development
HESI Concepts: Developmental, Teaching and Learning/Client Education
Awarded 1.0 points out of 1.0 possible points.
8. 8.ID: 9476988604
A nurse provides information about feeding to the mother of a 6-month-old
infant. Which statement by the mother indicates an understanding of the
information?
A. "I can mix the food in the my infant's bottle if he won't eat it."
B. "Fluoride supplementation is not necessary until permanent
teeth come in."
C. "Egg white should not be given to my infant because of the risk
for an allergy." Correct
D. "Meats are really important for iron, and I should start feeding
meats to my infant right away."
Rationale: Egg white, even in small quantities, is not given to the infant until the
end of the first year of life because it is a common food allergen. Fluoride
supplementation may be needed beginning at of 6 months, depending on the
infant’s intake of fluoridated tap water. Foods are never mixed with formula in
the bottle. It may be difficult for the infant to consume the formula, and it will
also be difficult to determine the infant’s intake of the formula. Solid foods may
be introduced into the diet when the infant is 5 to 6 months old. Rice cereal
may be introduced first because of its low allergenic potential; or, depending on
the pediatrician’s preference, fruits and vegetables may be introduced first.
Test-Taking Strategy: Note the words “indicates an understanding of theinformation.” Read each option carefully and think about the principles
associated with feeding and nutrition. Recalling that allergy is a concern will
direct you to the correct option. Review: the principles related to nutrition an
infant.
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J.
(2013). Maternal-child nursing (4th ed., p. 102). St. Louis: Elsevier.
Hockenberry, M., & Wilson, D. (2013). Wong’s Essentials of pediatric
nursing (9th ed., p. 329). St. Louis: Mosby.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Nutrition
Giddens Concepts: Development, Nutrition
HESI Concepts: Developmental, Nutrition
Awarded 1.0 points out of 1.0 possible points.
9. 9.ID: 9476995316
A nurse provides instructions to a mother of a newborn infant who weighs 7 lb 2
oz (3.2 kg) about car safety. What should the nurse tell the mother?
A. To secure the infant in the middle of the back seat in a rearfacing infant safety seat Correct
B. To place the infant in a booster seat in the front seat of the car
with the shoulder and lap belts secured around the infant
C. That it is acceptable to place the infant in the front seat in a
rear-facing infant safety seat as long as the car has passenger-side
air bags
D. That because of the infant's weight it is acceptable to hold the
infant as long as the mother and infant are sitting in the middle of
the back seat of the car
Rationale: Infants should not be restrained in the front seats of cars. If a
passenger-side air bag is deployed, the air bag may severely jolt an infant
safety seat, harming the infant. Infants weighing less than 20 lb (9.1 kg) and
those younger than 1 year should always be in the middle of the back seat in a
rear-facing car safety seat. An infant must be placed in an infant safety seat
and is never to be held by another person when riding in a car.
Test-Taking Strategy: Eliminate the options that are comparable or alike and
recommend placing the infant in the front seat. To select from the remaining
options, keep safety in mind and remember that the infant should never be held
and should be placed in an infant safety seat. Review: car safety principles for
an infant.
References: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J.
(2013). Maternal-child nursing (4th ed., pp. 107-108). St. Louis: Elsevier.American Academy of Pediatrics for information on car
safety www.healthychildren.org/English/safety-prevention/on-thego/Pages/Car-Safety-Seats-Information-for-Families.aspx.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Safety
Giddens Concepts: Development, Safety
HESI Concepts: Developmental, Safety
Awarded 1.0 points out of 1.0 possible points.
10. 10.ID: 9476993884
A nurse provides instructions to a mother about crib safety for her infant. Which
statement by the mother indicates a need for further instructions?
A. "I need to keep large toys out of the crib."
B. "The drop side needs to be impossible for my infant to
release."
C. "Wood surfaces on the crib need to be free of splinters and
cracks."
D. "The distance between the slats needs to be no more than 4
inches (10 cm) wide to prevent entrapment of my infant's head or
body." [Show Less]