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Import Settings:
Base Settings: Brownstone Default
Information Field: Client Needs
Information Field: Client Needs 2
Information Field: Cognitive Level
Information Field: Page
Highest Answer Letter: E
Multiple Keywords in Same Paragraph: No
Chapter: Chapter 29: Nursing Care of a Family with an Infant
Multiple Choice
1. The mother of a 3-month-old is concerned because her daughter does not yet sit by
herself. Which statement best reflects average sitting ability?
A) Most babies sit steadily at 3 months; she is slightly delayed.
B) Most babies do not sit steadily until 8 months; she is normal.
C) Sitting ability and the age of first tooth eruption are correlated.
D) Most babies sit steadily at 4 months; she is normal.
Ans: B
Client Needs: Health Promotion and Maintenance
Cognitive Level: Understand
Page: 788
Feedback: Many infants sit steadily by 8 months of age.
2. A 3-month-old still has a Moro reflex. Which statement is most true of this reflex?
A) A Moro reflex normally lasts until 9 months.
B) It is not important how long the reflex persists, only that it is present at birth.
C) A Moro reflex present at 3 months of age requires referral for a neurologic exam.
D) Most 3-month-olds still have a Moro reflex.
Ans: D

Cognitive Level: Understand
Page: 785
Feedback: Typically, Moro (startle) reflexes last until 5 to 6 months and then fade.
3. Which developmental task, according to Erikson, should an infant accomplish during

the infant year?
A) Adaptation
B) Trust
C) Learning and interaction
D) Autonomy
Ans: B
Cognitive Level: Remember
Page: 791
Feedback: The developmental task of the infant year, according to Erikson, is to gain a sense of
trust or knowing how to love.
4. The best way for an infant's father to help his child complete the developmental task of
the first year is to:
A) expose her to many caregivers to help her learn variability.
B) talk to her at a special time each day.
C) respond to her consistently.
D) keep her stimulated with many toys.
Ans: C
Cognitive Level: Apply
Page: 792
Feedback: A sense of trust is difficult to learn if things are constantly changing. Consistently
responding to an infant's needs helps to build a sense of trust.
5. Anticipatory guidance for an infant for the 4th month should include the fact that
she probably will:
A) develop a fear of strangers.
B) be able to turn over onto the back.
C) insist on things being done her way.

D) have many “blue” or moody periods.
Ans: B
Page: 783
Feedback: Infants typically turn over front to back at 4 months, enlarging the area of the house
that needs to be childproofed.
6. An infant is breast-fed. When assessing her stools, which findings would be typical?
A) Stools of breast-fed infants are usually harder than those of bottle-fed infants.
B) Breast-fed infants usually have fewer stools than bottle-fed infants.
C) Breast-fed infants are less likely to be constipated than bottle-fed infants.
D) Stools of breast-fed infants tend to have a strong odor.
Ans: C
Page: 803
Feedback: The stools of breastfed infants tend to be yellow and looser than those of bottle-fed
babies.
7. Which milestone would you expect an infant to accomplish by 8 months of age?

A) Sitting without support
B) Creeping on all fours
C) Pulling self to a standing position
D) Being able to sit from a standing position
Ans: A
Page: 785
Feedback: Most babies sit steadily at 8 months, creep at 9 months, and pull to standing at 10
months.
8. The nurse is caring for a 2-month-old with colic. When assessing the infant, the nurse asks
her parents about her bowel movements. Which characteristics of the bowel movement
are anticipated in a child with colic?
A) Loose and mucus-streaked.
B) Foul smelling and bulky.
C) Constipated and hard
D) Yellow and semi-formed.
Ans: D
Client Needs: Physiological Integrity: Reduction of Risk Potential
Page: 805
Feedback: There is no change in characteristics of the bowel movements in an infant with colic.
Infants have yellow seedy and typically semi-formed stools. Stools are typically normal in
amount, consistency, and color.
9. What information would you include when teaching the parents of an infant about colic?
A) Colic symptoms will probably fade at 3 months of age.
B) Their child will need future follow-up for a “nervous” bowel.
C) Formula intake should be doubled to keep her from losing weight.
D) Symptoms will decrease if she is laid on her back after feedings.
Ans: A
Client Needs: Physiological Integrity: Physiological Adaptation
Page: 804
Feedback: Colic symptoms typically fade at 3 months of age, probably because children begin
to maintain a more upright position at that time.
10. The mother of an infant asks you when to begin brushing her son's teeth. Your
best response would be:
A) as soon as the first tooth erupts.
B) by 12 months of age.
C) when weaning is complete.
D) as soon as he begins to eat fruit.
Ans: A
Page: 793
Feedback: Toothbrushing should begin with the eruption of the first tooth.
11. Estimating illness in an infant is difficult. To help an infant's parents do this, which of the
following would you instruct them to use?
A) Take her temperature about once a week.
B) Call if she spits up any formula.
C) Use her interest in eating as a good gauge.
D) Call if the infant's stools are yellow.
Ans: C
Page: 808
Feedback: A healthy infant eats well, voids adequately, and gains weight.
12. A father asks the nurse what symptoms he can expect with normal teething in his infant.
What would the nurse tell him?
A) The child's gumline will be tender.
B) The child will not play or eat for 2 days.
C) He can expect his child to be constipated for 2 days.
D) The child's temperature may go as high as 102°F.
Ans: A
Client Needs: Physiological Integrity: Reduction of Risk Potential
Page: 802
Feedback: Normal teething creates tender gumlines but does not include an elevated
temperature or constipation.
13. Which measure would you suggest an infant's parents use to relieve teething discomfort?
A) Provide her with a fluid diet for 2 days.
B) Offer her Aspergum to chew.
C) Ask her pediatrician for a sedative for her.
D) Give her a cold teething ring to chew.
Ans: D
Client Needs: Physiological Integrity: Basic Care and Comfort
Page: 802
Feedback: Cold can be very soothing for the tender gumlines during teething. A sedative is not
necessary for normal teething discomfort.
14. When teaching an infant's mother about bathing her, it would be important to instruct her
that:
A) infants need a daily bath.
B) soap lubricates and oils an infant's skin.
C) bath time provides an opportunity for play.
D) she should never use soap on a baby's hair.
Ans: C
Page: 800
Feedback: Infants do not need a daily bath as long as the diaper area is washed with diaper
changes. Soap is actually drying to an infant's skin. Washing the hair with soap can help
remove excess oil.
15. Infant development is best described by which statement?

A) Development varies greatly from infant to infant.
B) Development is not sequential but predictable.
C) Development proceeds from fine to gross.
D) Development proceeds cephalocaudally.
Ans: D
Page: 783
Feedback: Growth and development both proceed from head to toe, or in a cephalocaudal
sequence.
16. The mother of a 3-month-old baby is concerned because the child is not able to sit
independently. How should the nurse respond to this mother's concern?
A) Most babies sit steadily at 3 months.
B) Most babies sit steadily at 4 months.
C) Most babies do not sit steadily until 8 months.
D) Sitting ability and the age of first tooth eruption are correlated.
Ans: C
Client Needs: Safe, Effective Care Environment: Management of Care
Client Needs 2: Health Promotion and Maintenance
Page: 784
Feedback: An 8-month-old child can sit securely without any additional support. Babies are not
able to sit steadily at age 3 or 4 months. Sitting ability does not correspond with tooth eruption.
17. During an assessment, the nurse determines that a 3-month-old baby has a Moro
reflex. What does this finding indicate to the nurse?
A) It usually lasts until 9 months.
B) It will persist until the age of 1 year.
C) Most 3-month-olds still have a Moro reflex.
D) If present at 3 months of age, a neurologic exam is needed.
Ans: C
Cognitive Level: Analyze
Page: 785
Feedback: The Moro reflex will begin to fade at age 5 months and disappear by age 6 months.
A Moro reflex at age 9 months or 1 year indicates the need for a neurologic examination.
Multiple Selection
18. The nurse is planning an educational seminar for community members that focuses on
the 2020 National Health Goals to promote health during the infant year. What should the
nurse include in this seminar? Select all that apply.
A) Using infant car seats
B) Placing infants on back to sleep
C) Continuing breast-feeding for 6 months
D) Introducing solid food by age 6 months
E) Receiving immunizations after the age of 1
Ans: A, B, C

Page: 779
Feedback: Nurses can help the nation achieve the 2020 National Health Goals to promote health
during the infant year by educating parents about the importance of using infant car seats,
continuing exclusive breastfeeding for 6 months, and instigating measures to prevent SIDS such
as placing infants to sleep on their backs. The introduction of solid food would occur after the
age of 6 months. Immunizations are provided throughout the infant year.
Multiple Choice
19. What should the nurse instruct a parent to help a child complete Erikson's developmental
task during the infant period?
A) Respond to the child's needs consistently.
B) Keep the child stimulated with many toys.
C) Talk to the child at a special time each day.
D) Expose the child to many caregivers to help learn variability.
Ans: A
Client Needs 2: Physiological Integrity: Basic Care and Comfort
Page: 791-792
Feedback: Consistently responding to an infant's needs helps to build a sense of trust, which is
Erikson's developmental task during the infant period. Stimulation with toys, talking at a special
time each day, and exposing too many caregivers will not help the child develop a sense of trust.
20. The nurse is visiting a mother who has a 3-month-old infant. Which anticipatory
guidance information should the nurse provide to the mother at this time?
A) The child will have a fear of strangers.
B) The child will experience many moody periods.
C) The child will expect things to be done a certain way.
D) The child should be able to turn over onto the back at age 4 months.
Ans: D

Page: 795
Feedback: Infants typically turn over from the front to back at age 4 months. Fear of strangers
will not occur until 7 months. The nurse has no way of knowing the infant's temperament to
determine that the child will be moody or when the child will expect things to be done a certain
way.
21. The nurse is assessing an infant who is being breast-fed. Which observation regarding
the infant's stools is expected?
A) Fewer stools
B) Stool will be soft.
C) Stool will be hard.
D) Stool will have a strong odor.
Ans: B
Page: 803
Feedback: Stools of breast-fed infants are generally softer than those of formula-fed infants.
Stools of breastfed infants are not fewer in number, hard, nor have a strong odor.
22. The nurse is identifying outcomes for care provided to a new mother whose infant continues
to spit up after feedings. Which outcome would be the most appropriate?
A) The baby will have forceful episodes of vomitus only once a day.
B) The baby will have less episodes of spitting up after sitting upright after a feeding.
C) The baby will spit up a large amount of vomitus only after the last feeding of the day.
D) The baby will have fewer episodes of spitting up when the type of formula is changed.
Ans: B
Page: 804-806
Feedback: Sitting a baby in an infant chair for a half an hour after a feeding can help reduce
spitting up. Forceful episodes of vomitus and vomiting large amounts after feedings should be
reported to the health care provider. Changing the formula will not impact the amount of
spitting up the baby.
23. The nurse is assessing a 2-month-old formula-fed infant who is experiencing colic. Which
type of bowel movements should the nurse expect to occur with this health problem?
A) Hard and lumpy
B) Yellow and semisoft
C) Foul smelling and bulky
D) Loose and mucus-streaked
Ans: B
Client Needs 2: Physiological Integrity: Reduction of Risk Potential
Page: 805
Feedback: With colic, bowel movements are normal. For an infant who is formula-fed this
means the stool will be yellow and semisoft. Colic does not affect the type of bowel
movement so changes in the stool such as hard and lumpy, foul smelling and bulky, and loose
and mucus-streaked should be reported to the health care provider.
24. The nurse is visiting a mother who has a 3-month-old infant who has been hospitalized for
cardiac problems. Which nursing diagnosis should the nurse use to guide care for this family at
this time?
A) Health-seeking behaviors related to adjusting to parenthood
B) Risk for impaired parenting related to hospitalization of infant
C) Disturbed maternal sleep pattern related to infant's feeding schedule
D) Deficient knowledge related to normal infant growth and development
Ans: B
Client Needs: Psychosocial Integrity
Client Needs 2: Safe, Effective Care Environment: Management of Care
Page: 779
Feedback: The diagnosis appropriate for the family whose infant has been hospitalized would
be risk for impaired parenting related to hospitalization. There is no evidence to suggest that
the mother is not adjusting to parenthood. There is no information about the infant's feeding
schedule. There is no information to suggest the mother has a knowledge deficit regarding
normal infant growth and development.
25. A new mother asks the nurse when toothbrushing should begin for the baby. Which
response is the most appropriate for the nurse to make at this time?
A) Now
B) At the age of 12 months
C) When solid food is eaten
D) When the first tooth appears
Ans: A
Page: 801
Feedback: Toothbrushing can begin even before teeth erupt by rubbing a soft washcloth over
the gum pads. This eliminates plaque and reduces the presence of bacteria, creating a clean
environment for the arrival of first teeth. Dental care should begin before the age of 12
months, before solid food is eaten, and before the first tooth appears.
26. The mother of a 4-month-old infant is concerned that the baby does not always want to
take a bottle. What should the nurse instruct the mother about feeding the baby?
A) Ensure the environment is quiet during mealtime.
B) Happy and healthy babies do not always eat well.
C) Force the infant to take a bottle when it is time to do so.
D) Refusing a bottle means the child is ill and needs to be seen by the health care provider.
Ans: A
Page: 805
Feedback: If infants are fatigued or overstimulated, they also may not eat well. Providing a quiet
environment away from distractions before mealtime might be the solution to this problem.
Healthy happy babies will be hungry at mealtime and will eat. The mother should not force the
baby to take a bottle when it is time to do so. Refusing a bottle may mean that the baby is tired,
distracted, or ill. The baby does not always need to be seen by a health care provider when a
bottle is refused.
27. A new mother asks the nurse what she should look for when the baby starts to teethe.
What should the nurse explain to the mother?
A) The child's gum line will be tender.
B) The child will have a high temperature.
C) The child will not play or eat for 2 days.
D) The child will be constipated for 2 days.
Ans: A
Page: 802
Feedback: Gums are sore and tender before a new tooth breaks the surface. As soon as the tooth
is through, the tenderness passes. A high temperature is not a normal expectation with teething
and should be reported to the health care provider. The child may resist chewing because of the
sore gum; however, it may not last for 2 days. Playing may or may not be affected. Constipation
is not an expectation with teething.
28. During a home visit, the nurse observes a 9-month-old child bang his head against the
headboard of the crib at naptime. What should the nurse explain to the mother about this
observation?
A) The child is eating too much protein.
B) The child is not getting enough to eat.
C) This action is normal up until preschool age.
D) The child needs to be seen immediately by a health care provider.
Ans: C
Page: 803
Feedback: Head banging that begins during the second half of the first year of life and
continuing through to the preschool period, associated with naptime or bedtime, and lasting
under 15 minutes can be considered normal. Children use this measure to relax and fall asleep.
Head banging does not mean that the child is eating too much protein or is not getting enough
to eat. The child does not need to be seen immediately by a health care provider.
29. The nurse observes a new mother bathing her 9-month-old baby. Which
observation indicates that the experience is positive for both mother and infant?
A) The baby is crying and screaming.
B) The baby is reaching for the mother.
C) The baby is moving the arms and hand and smiling.
D) The baby is trying to keep the legs from touching the water.
Ans: C

Page: 800
Feedback: Bath time should be fun for an infant and can serve many functions. Especially
during the second half of the first year, a child enjoys poking at soap bubbles on the surface of
the water or playing with bath toys. Bath time also helps an infant learn different textures and
sensations and provides an opportunity to exercise and kick as well as a good opportunity for a
parent to touch and communicate with the child. Crying, screaming, reaching for the mother,
and trying to avoid touching the water indicates that the bath experience is not positive for the
baby or the mother.
30. The nurse is concerned that a 9-month-old baby is gaining too much weight. What should
the nurse instruct the parents to help control the baby's weight gain?
A) Use skim milk for feedings.
B) Provide whole-grain cereal for one feeding.
C) Provide one bottle a day of diluted gelatin mix.
D) Feed the baby a serving of pudding once a day.
Ans: B
Client Needs 2: Physiological Integrity: Reduction of Risk Potential
Page: 807
Feedback: A way to prevent obesity is to add a source of fiber such as whole-grain cereal to the
infant's diet. This prolongs the stomach-emptying time and helps reduce food intake. Nonfat milk
should not be given because it contains little essential fatty acids and will not ensure cell growth.
The baby should not be given refined sugars such as diluted gelatin or pudding because this will
encourage weight gain.

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Chapter: Chapter 29: Nursing Care of a Family with an Infant

Client Needs: Health Promotion and Maintenance

3. Which developmental task, according to Erikson, should an infant accomplish during

C) insist on things being done her way.

7. Which milestone would you expect an infant to accomplish by 8 months of age?

15. Infant development is best described by which statement?

Client Needs: Safe, Effective Care Environment: Management of Care

Client Needs 2: Physiological Integrity: Basic Care and Comfort

D) The child will be constipated for 2 days.

Client Needs 2: Health Promotion and Maintenance

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