TEST BANK FOR ESSENTIALS OF PEDIATRIC NURSING CHAPTER 3 BY KYLE

1. The nurse is examining a 10-month-old boy who was born 10 weeks early. Which finding is cause for concern? a. The child has doubled his birth weight. b. The child exhibits plantar grasp reflex. c. The child’s head circumference is 49.53 cm. d. No primary teeth have erupted yet. ANS: C Feedback: The child’s head size is large for his adjusted age (7.5 months), which would be cause for concern. The average head circumference of the full-term newborn is 35 cm (13.5 in). Head circumference increases about 10 cm from birth to 1 year (Levine, 2019). Birth weight doubles by about 4 months of age. Plantar grasp reflex does not disappear until 9 months adjusted age. Primary teeth may not erupt until 8 months adjusted age. PTS: 1 REF: p. 60, Head Circumference NAT: Client Needs: Safe and Effective Care Environment: Management of Care KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 2. The nurse is teaching a new mother about the drastic growth and developmental changes her infant will experience in the first year of life. Which statement describes a developmental milestone occurring in infancy? a. By 6 months of age, the infant’s brain weighs half that of the adult brain; at age 12 months, the brain weighs 2.5 times what it did at birth. b. Most infants triple their birth weight by 4 to 6 months of age and quadruple their birth weight by the time they are 1 year old. c. The head circumference increases rapidly during the first 6 months: the average increase is about 1 in per month. d. The heart triples in size over the first year of life; the average pulse rate decreases from 120 to 140 in the newborn to about 100 in the 1-year-old. ANS: A Feedback: By 6 months of age, the infant’s brain weighs half that of the adult brain; at age 12 months, the brain weighs 2.5 times what it did at birth. Most infants double their birth weight by 4 to 6 months of age and triple their birth weight by the time they are 1 year old. The head circumference increases rapidly during the first 6 months: the average increase is about 0.6 in (1.5 cm) per month. The heart doubles in size over the first year of life. As the cardiovascular system matures, the average pulse rate decreases from 120 to 140 in the newborn to about 100 in the 1-year-old. PTS: 1 REF: p. 61, Brain Growth NAT: Client Needs: Physiological Integrity: Basic Care and Comfort KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice TEST BANK FOR ESSENTIALS OF PEDIATRIC NURSING 4TH BY KYLE WWW.NURSING-TESTBANK.COM TEST BANK FOR ESSENTIALS OF PEDIATRIC NURSING CHAPTER 3 BY KYLE N U R S I N G - T E S T B A N K . C O M 3. The nurse is assessing the respiratory system of a newborn. Which anatomic differences place the infant at risk for respiratory compromise? Select all that apply. a. The nasal passages are narrower. b. The trachea and chest wall are less compliant. c. The bronchi and bronchioles are shorter and wider. d. The larynx is more funnel shaped. e. The tongue is smaller. f. There are significantly fewer alveoli. ANS: A, D, F Feedback: In comparison with the adult, in the infant, the nasal passages are narrower, the trachea and chest wall are more compliant, the bronchi and bronchioles are shorter and narrower, the larynx is more funnel shaped, the tongue is larger, and there are significantly fewer alveoli. These anatomic differences place the infant at higher risk for respiratory compromise. The respiratory system does not reach adult levels of maturity until about 7 years of age. PTS: 1 REF: p. 61, Respiratory System NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Select 4. A new mother shows the nurse that her baby grasps her finger when she touches the baby’s palm. How might the nurse respond to this information? a. “This is a primitive reflex known as the plantar grasp.” b. “This is a primitive reflex known as the palmar grasp.” c. “This is a protective reflex known as rooting.” d. “This is a protective reflex known as the Moro reflex.” ANS: B Feedback: Primitive reflexes are subcortical and involve a whole-body response. Selected primitive reflexes present at birth include Moro, root, suck, asymmetric tonic neck, plantar and palmar grasp, step, and Babinski. During the palmar grasp, the infant reflexively grasps when the palm is touched. The plantar grasp occurs when the infant reflexively grasps with the bottom of the foot when pressure is applied to the plantar surface. The root reflex occurs when the infant’s cheek is stroked and the infant turns to that side, searching with mouth. The Moro reflex is displayed when with sudden extension of the head, the arms abduct and move upward and the hands form a “C.” PTS: 1 REF: p. 63, Table 3.1 NAT: Client Needs: Health Promotion and Maintenance KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 5. Which reflex, if found in a 4-month-old infant, would cause the nurse to be concerned? a. Plantar grasp b. Step c. Babinski d. Neck righting TEST BANK FOR ESSENTIALS OF PEDIATRIC NURSING 4TH BY KYLE WWW.NURSING-TESTBANK.COM N U R S I N G - T E S T B A N K . C O M ANS: B Feedback: Appropriate appearance and disappearance of primitive reflexes, along with the development of protective reflexes, indicates a healthy neurologic system. The step reflex is a primitive reflex that appears at birth and disappears at 4 to 8 weeks of age. The plantar grasp reflex is a primitive reflex that appears at birth and disappears at about the age of 9 months. The Babinski reflex is a primitive reflex that appears at birth and disappears around the age of 12 months. The neck righting reflex is a protective reflex that appears around the age of 4 to 6 months and persists. PTS: 1 REF: p. 64, Table 3.1 NAT: Client Needs: Health Promotion and Maintenance KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 6. A new mother expresses concern to the nurse that her baby is crying and grunting when passing stool. What is the nurse’s best response to this observation? a. “This is normal behavior for infants unless the stool passed is hard and dry.” b. “This is normal behavior for infants due to the immaturity of the gastrointestinal system.” c. “This indicates a blockage in the intestine and must be reported to the healthcare provider.” d. “This is normal behavior for infants unless the stool passed is black or green.” ANS: A Feedback: Due to the immaturity of the gastrointestinal system, newborns and young infants often grunt, strain, or cry while attempting to have a bowel movement. This is not of concern unless the stool is hard and dry. Stool color and texture may change depending on the foods that the infant is ingesting. Iron supplements may cause the stool to appear black or very dark green. PTS: 1 REF: p. 65, Stools NAT: Client Needs: Physiological Integrity: Basic Care and Comfort KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 7. The neonatal nurse assesses newborns for iron deficiency anemia. Which newborn is at highest risk for this disorder? a. A postterm newborn b. A term newborn with jaundice c. A newborn born to a diabetic mother d. A premature newborn ANS: D Feedback: TEST BANK FOR ESSENTIALS OF PEDIATRIC NURSING 4TH BY KYLE WWW.NURSING-TESTBANK.COM N U R S I N G - T E S T B A N K . C O M Maternal iron stores are transferred to the fetus throughout the last trimester of pregnancy. Infants born prematurely miss all or at least a portion of this iron store transfer, placing them at increased risk for iron deficiency anemia compared with term infants. An infant having jaundice, having been born to a mother with diabetes, or having been born postterm does not significantly place the infant at risk for iron deficiency anemia. PTS: 1 REF: p. 67, Take Note! NAT: Client Needs: Health Promotion and Maintenance KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 8. The nurse caring for newborns knows that infants exhibit phenomenal increases in their gross motor skills over the first 12 months of life. Which statements accurately describe the typical infant’s achievement of these milestones? Select all that apply. a. At 1 month, the infant lifts and turns the head to the side in the prone position. b. At 2 months, the infant rolls from supine to prone to back again. c. At 6 months, the infant pulls to stand up. d. At 7 months, the infant sits alone with some use of hands for support. e. At 9 months, the infant crawls with the abdomen off the floor. f. At 12 months, the infant walks independently. ANS: A, D, E, F Feedback: At 1 month, the infant lifts and turns the head to the side in the prone position. At 7 months, the infant sits alone with some use of hands for support. At 9 months, the infant crawls with the abdomen off the floor. At 12 months, the infant walks independently. At 4 months, the infant lifts the head and looks around. At 10 months, the infant pulls to stand up. PTS: 1 REF: p. 68, Table 3.3 NAT: Client Needs: Health Promotion and Maintenance KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Select 9. The nurse is teaching a new mother about the development of sensory skills in her newborn. What would alert the mother to a sensory deficit in her child? a. The newborn’s eyes wander and occasionally are crossed. b. The newborn does not respond to a loud noise. c. The newborn’s eyes focus on near objects. d. The newborn becomes more alert with stroking when drowsy. ANS: B Feedback: Though hearing should be fully developed at birth, the other senses continue to develop as the infant matures. The newborn should respond to noises. Sight, smell, taste, and touch all continue to develop after birth. The newborn’s eyes wander and occasionally cross, and the newborn is nearsighted, preferring to view objects at a distance of 8 to 15 in. Holding, stroking, rocking, and cuddling calm infants when they are upset and make them more alert when they are drowsy. PTS: 1 REF: p. 70, Take Note! TEST BANK FOR ESSENTIALS OF PEDIATRIC NURSING 4TH BY KYLE WWW.NURSING-TESTBANK.COM N U R S I N G - T E S T B A N K . C O M NAT: Client Needs: Health Promotion and Maintenance KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze NOT: Multiple Choice 10. The nurse is assessing a 4-month-old boy during a scheduled visit. Which findings might suggest a developmental problem? a. The child does not babble. b. The child does not vocally respond to voices. c. The child never squeals or yells. d. The child does not say dada or mama. ANS: B Feedback: The fact that the child does not vocally respond to voices might suggest a developmental problem. At 4 to 5 months of age, most children are making simple vowel sounds, laughing aloud, doing raspberries, and vocalizing in response to voices. The child is too young to babble, squeal, yell, or say dada or mama. PTS: 1 REF: p. 70, Communication and Language Development NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 11. The nurse observes an infant interacting with his parents. What are normal social behavioral developments for this age group? Select all that apply. a. Around 5 months, the infant may develop stranger anxiety. b. Around 2 months, the infant exhibits a first real smile. c. Around 3 months, the infant smiles widely and gurgles when interacting with the caregiver. d. Around 3 months, the infant will mimic the parent’s facial movements, such as sticking out the tongue. e. Around 3 to 6 months of age, the infant may enjoy socially interactive games such as patty-cake and peek-a-boo. f. Separation anxiety may also start in the last few months of infancy. ANS: B, C, D, F Feedback: The infant exhibits a first real smile at age 2 months. By about 3 months of age, the infant will start an interaction with a caregiver by smiling widely and possibly gurgling. The 3- to 4-month-old will also mimic the parent’s facial movements, such as widening the eyes and sticking out the tongue. Separation anxiety may also start in the last few months of infancy. Around the age of 8 months, the infant may develop stranger anxiety. At 6 to 8 months of age, the infant may enjoy socially interactive games such as patty-cake and peek-a-boo. PTS: 1 REF: p. 73, Social and Emotional Development NAT: Client Needs: Health Promotion and Maintenance KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Select