PEDS CH 25

The nurse is examining a 10-month-old boy who was born 10 weeks early. Which finding is cause for concern?

• The child has doubled his birth weight.
• The child exhibits plantar grasp reflex.
• The child's head circumference is 49.53 cm.
• No primary teeth have erupted yet.

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?

• 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 triple their birth weight by 4 to 6 months of age and quadruple 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 1 in per month.
• 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.

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.

• The nasal passages are narrower.
• The trachea and chest wall are less compliant.
• The bronchi and bronchioles are shorter and wider.
• The larynx is more funnel shaped.
• There are significantly fewer alveoli.

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?

• "This is a primitive reflex known as the plantar grasp."
• "This is a primitive reflex known as the palmar grasp."
• "This is a protective reflex known as rooting."
• "This is a protective reflex known as the Moro reflex."

Which reflex, if found in a 4-month-old infant, would cause the nurse to be concerned?

• Plantar grasp
• Step
• Babinski
• Neck righting

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?

• "This is normal behavior for infants unless the stool passed is hard and dry."
• "This is normal behavior for infants due to the immaturity of the gastrointestinal system."
• "This indicates a blockage in the intestine and must be reported to the health care provider."
• "This is normal behavior for infants unless the stool passed is black or green."

The neonatal nurse assesses newborns for iron deficiency anemia. Which newborn is at highest risk for this disorder?

• A postterm newborn
• A term newborn with jaundice
• A newborn born to a diabetic mother
• A premature newborn

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.

• At 1 month, the infant lifts and turns the head to the side in the prone position.
• At 2 months, the infant rolls from supine to prone to back again.
• 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.

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?

• The newborn's eyes wander and occasionally are crossed.
• The newborn does not respond to a loud noise.
• The newborn's eyes focus on near objects.
• The newborn becomes more alert with stroking when drowsy.

The nurse is assessing a 4-month-old boy during a scheduled visit. Which findings might suggest a developmental problem?

• The child does not babble.
• The child does not vocally respond to voices.
• The child never squeals or yells.
• The child does not say dada or mama.