NURSING 2362 Module 1 Exam
Questions
1. ID: 8482548610A nurse is providing information to a group of pregnant clients
and their partners about the psychosocial development of an infant. Using Erikson's theory of
psychosocial development, what should the nurse tell the group about the infants?
Rely on the fact that their needs will be met Correct
Need to tolerate a great deal of frustration and discomfort to develop a healthy personality
Must have needs ignored for short periods to develop a healthy personality
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). Maternal-
child 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. ID: 8482544657A 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. The nurse notes that the infant now weighs 13 lb. Which action should the nurse take?
Tell the mother that the infant's weight is increasing as expected Correct
Tell the mother to decrease the daily number of feedings because the weight gain is excessive
Tell the mother that semisolid foods should not be introduced until the infant's weight stabilizes
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, at birth, a weight of 13 lb 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. ID: 8482548652A 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?
Suspect the presence of hydrocephalus
Suggest to the pediatrician that a skull x-ray be performed
Tell the mother that the infant is growing faster than expected
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 and
indicate 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. ID: 8482544621A 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?
"Yes, your infant is protected from all infections."
"If you breastfeed, your infant is protected from infection."
"The transfer of your antibodies protects your infant until the infant is 12 months old."
"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 Environment
Integrated 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. ID: 8482544611A 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?
The infant babbles.
The infant says "Mama." Correct
The infant smiles and coos.
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. ID: 8482544667The 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?
Schedule an appointment with a dentist for a dental evaluation
, Rub the infant's gums with baby aspirin that has been dissolved in water
Obtain an over-the-counter (OTC) topical medication for gum-pain relief
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. ID: 8482544675A 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?
Use water and a cotton swab and rub the teeth Correct
Use diluted fluoride and rub the teeth with a soft washcloth
Use a small amount of toothpaste and a soft-bristle toothbrush
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 of fluoride 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).
