The nurse is checking reflexes on a 7-month-old infant. When the infant is suspended in a horizontal prone position, the head is raised and the legs and spine are extended. Which reflex is this?
- A. Landau
- B. Parachute
- C. Body righting
- D. Labyrinth righting
Correct Answer: A
Rationale: When the infant is suspended in a horizontal prone position, the head is raised and the legs and spine are extended; this describes the Landau reflex. It appears at 6 to 8 months and persists until 12 to 24 months. The parachute reflex occurs when the infant is suspended in a horizontal prone position and suddenly thrust downward; the infant extends the hands and fingers forward as if to protect against falling. This appears at age 7 to 9 months and lasts indefinitely. Body righting occurs when turning the hips and shoulders to one side causes all other body parts to follow. It appears at 6 months of age and persists until 24 to 36 months. The labyrinth-righting reflex appears at 2 months and is strongest at 10 months. This reflex involves holding infants in the prone or supine position. They are able to raise their heads.
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The nurse is interviewing the father of a 10-month-old girl. The child is playing on the floor when she notices an electrical outlet and reaches up to touch it. Her father says no firmly and moves her away from the outlet. The nurse should use this opportunity to teach the father what?
- A. That the child should be given a time-out
- B. That the child is old enough to understand the word no
- C. That the child will learn safety issues better if she is spanked
- D. That the child should already know that electrical outlets are dangerous
Correct Answer: B
Rationale: By age 10 months, children are able to associate meaning with words. The father is using both verbal and physical cues to alert the child to dangerous situations. A time-out is not appropriate. The child is just learning about the environment. Physical discipline should be avoided. The 10-month-old child is too young to understand the purpose of an electrical outlet.
What is an appropriate play activity for a 7-month-old infant to encourage visual stimulation?
- A. Playing peek-a-boo
- B. Playing pat-a-cake
- C. Imitating animal sounds
- D. Showing how to clap hands
Correct Answer: A
Rationale: Because object permanence is a new achievement, peek-a-boo is an excellent activity to practice this new skill for visual stimulation. Playing pat-a-cake and showing how to clap hands help with kinetic stimulation. Imitating animal sounds helps with auditory stimulation.
Which intervention is the most appropriate recommendation for relief of teething pain?
- A. Rub gums with aspirin to relieve inflammation.
- B. Apply hydrogen peroxide to gums to relieve irritation.
- C. Give the infant a frozen teething ring to relieve inflammation.
- D. Have the infant chew on a warm teething ring to encourage tooth eruption.
Correct Answer: C
Rationale: Teething pain is a result of inflammation, and cold is soothing. A frozen teething ring or ice cube wrapped in a washcloth helps relieve the inflammation. Aspirin is contraindicated secondary to the risks of aspiration. Hydrogen peroxide does not have an anti-inflammatory effect. Warmth increases inflammation.
The parents of a 2-month-old boy are concerned about spoiling their son by picking him up when he cries. What is the nurses best response?
- A. Allow him to cry for no longer than 15 minutes and then pick him up.
- B. Babies need comforting and cuddling. Meeting these needs will not spoil him.
- C. Babies this young cry when they are hungry. Try feeding him when he cries.
- D. If he isnt soiled or wet, leave him, and hell cry himself to sleep.
Correct Answer: B
Rationale: Parents need to learn that a spoiled child is a response to inconsistent discipline and limit setting. It is important to meet the infants developmental needs, including comforting and cuddling. The data suggest that responding to a childs crying can actually decrease the overall crying time. Allowing him to cry for no longer than 15 minutes and then picking him up will reinforce prolonged crying. Infants at this age have other needs besides feeding. The parents should be taught to identify their infants cues. Counseling parents on letting the baby cry himself to sleep when not soiled or wet refers to sleep issues, not general infant behavior.
The nurse is discussing development and play activities with the parent of a 2-month-old boy. Which statement by the parent would indicate a correct understanding of the teaching?
- A. I can give my baby a ball of yarn to pull apart or different textured fabrics to feel.
- B. I can use a music box and soft mobiles as appropriate play activities for my baby.
- C. I can use a cup and spoon or push-pull toys for my baby at this age.
- D. I do not have to worry about appropriate play activities at this age.
Correct Answer: B
Rationale: Music boxes and soft mobiles are appropriate play activities for a 2-month-old infant. A ball of yarn to pull apart or different textured fabrics are appropriate for an infant at 6 to 9 months. A cup and spoon or push-pull toys are appropriate for an older infant. Infants of all ages should be exposed to appropriate types of stimulation.
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