The clinic administrator has asked each nurse to classify the nursing activities as a beginning step of clinic reorganization. Which of these strategies can be classified as health promotion and health maintenance? Select all that apply.
- Instructing on how to use dental floss
- Treating a child with a diagnosis of acute otitis media
- Administering the flu vaccine to infants 6 to 23 months old
- Working with new parents to create daily feeding schedules for infants
- Conducting developmental screening examinations for toddlers
1,3,4,5
The mother of a newborn asks the nurse what the purpose of the first scheduled health maintenance visit will be. Which are appropriate responses by the nurse to this question? Select all that apply.
- “To determine if your baby is being abused.”
- “To determine compatibility between you and the provider.”
- “To discuss policies related to provision of care.”
- “To evaluate your understanding of the services offered.”
- “To determine your baby’s risk for obesity.”
2,3,4
During a health supervision visit, the nurse is attempting to develop a partnering relationship with the child and family. Which is the initial action by the nurse?
- Telling the family what the child should be doing physically for the age level
- Telling the family that the healthcare provider will answer any questions they might have related to their child’s growth and development
- Setting goals for the family related to the child’s health
- Discussing a plan with the family to address the child’s health needs
4
During a scheduled health maintenance visit for a 6-month-old infant the nurse asks, “Does the baby sit without assistance, and is the baby crawling?” Which process is the nurse using in this interaction?
- Health promotion
- Developmental surveillance
- Health maintenance
- Disease surveillance
2
A parent says to a nurse, “How do you know when my baby needs these screening tests the doctor just mentioned?” Which response by the nurse is most appropriate?
- “Screening tests are done in the newborn nursery, and from these results, additional screening tests are ordered throughout the first 2 years of life.”
- “Screening tests are done at each office visit.”
- “Screening tests are most often done when the doctor suspects something is wrong with the child.”
- “Screening tests are administered at the ages when a child is most likely to develop a condition.”
4
The nurse is working with first-time parents. Which activity will the nurse suggest to encourage the development of good muscle tone in their infant?
- Placing the infant in an infant seat rather than lying down in a crib
- Surrounding the infant with toys and other stimulating items to encourage motor movement
- Swaddling the infant
- Putting the infant to bed each night at 8 p.m., even if the infant protests with crying
2
A mother who is bottlefeeding her newborn is discharged 48 hours postdelivery. When should the nurse schedule the first office visit for the newborn with the pediatrician?
- Within 5 days of discharge
- Within 7 days of discharge
- Within 2 weeks of discharge
- Within 3 weeks of discharge
1
While interviewing the parents of a toddler-age client, the nurse notes that the mother is pregnant. At the end of the visit, the nurse decides to give a new pamphlet to the parents about car seat usage for newborns. Which is the purpose of this action by the nurse?
- Secondary preventative health maintenance
- Developmental health screening
- Tertiary preventative health maintenance
- Primary preventative health maintenance
4
A nurse assesses the height and weight measurements on an infant and documents these measurements at the 75th percentile. The nurse notes that the measurements 2 months ago were at the 25th percentile. Which interpretation of these data by the nurse is accurate?
- The infant is not gaining enough weight.
- The infant has gained a significant amount of weight.
- These measurements most likely are inaccurate.
- The previous measurements were most likely inaccurate.
2
The mother of a 2-year-old child becomes very anxious when the child has a temper tantrum in the medical office. Which response by the nurse to the mother is appropriate?
- “Let’s ignore this behavior. It will stop sooner.”
- “What do you usually do or say during a temper tantrum?”
- “This is definitely a temper tantrum. I know exactly what you are feeling right now.”
- “Pick up and cuddle your child now, please.”
2
Parents are in the pediatric clinic with their infant for a 1-month checkup. Which assessment question regarding immunizations should the nurse ask the infant’s parents?
- “Did your baby receive the influenza vaccine prior to hospital discharge?”
- “Did your baby receive the hepatitis B vaccine prior to hospital discharge?”
- “Did your baby receive the rubella vaccine prior to hospital discharge?”
- “Did your baby receive the rotavirus vaccine prior to hospital discharge?”
2
A nurse is assessing an 11-month-old infant, and notes that the infant’s height and weight are at the 5th percentile on the growth chart; the infant was previously plotted at the 25th percentile. Psychosocial history reveals that the parents are separated and are planning to divorce. Which is the priority when planning this infant’s care?
- Parental anxiety
- Risk for failure to thrive
- Excessive nutritional intake
- Risk for injury
2
Which observation in a health supervision visit leads the nurse to have concerns about the infant’s mental health?
- A 1-month-old is swaddled by the parent because of crying after an immunization.
- A 7-month-old infant grabs her mother and cries when the nurse attempts touch.
- A 9-month-old avoids eye contact with parents and the nurse.
- A 10-month-old reportedly sleeps about 12 hours total per night.
3
The nurse is assessing a small-for-gestational-age newborn who had an older sibling who died of sudden infant death syndrome (SIDS). Which should the nurse include in the newborns plan of care based on these data?
- Encourage the parents to sleep with the newborn for close observation.
- Encourage the parents to place the newborn on the abdomen to sleep.
- Encourage the parents to place the newborn in a crib with a tight-fitting, firm mattress.
- Encourage the parents to place the newborn in a crib with a soft mattress with extra blankets.
3
Which nursing actions are appropriate for the 2-month-old infant during a scheduled health maintenance visit? Select all that apply.
- Reviewing infant fluid needs with the parents
- Reinforcing the importance of heating bottles with water versus the microwave
- Demonstrating proper gum care to the parents
- Educating the parents to begin introducing solid foods, such as rice cereal
- Recommending that juice be introduced in a sippy cup
1,2,3
) Which topics are appropriate for the nurse to include when teaching preventive disease strategies during infancy? Select all that apply.
- Metabolic screenings
- Hearing screenings
- Risks of environmental smoke exposure
- Stranger danger strategies
- Bike safety
1,2,3
Which actions are appropriate when the nurse is performing general observations during the assessment process for an infant? Select all that apply.
- Asking the family how they are adjusting to having the infant in the home
- Monitoring the parents for clinical manifestations associated with fatigue
- Assessing for behaviors that indicate appropriate bonding
- Placing the infant on the scale for a weight and length assessment
- Auscultating heart and lung sounds while the infant is asleep
1,2,3
What is the purpose of making general observations during the assessment process for an infant during a scheduled health maintenance visit? Select all that apply.
- To invite discussion with the parents
- To validate positive parenting efforts
- To promote a partnership between healthcare providers and parents
- To decrease the risk of communicable diseases
- To meet standards required for The Joint Commission accreditation
1,2,3
The nurse is preparing for a health maintenance visit for a 9-month-old infant. Which teaching topics are appropriate for the nurse to include during the scheduled visit? Select all that apply.
- Using iron-fortified formula
- Encouraging self-feeding of finger foods
- Increasing the number of daily milk feedings
- Encouraging cups for all feedings
- Introducing burping techniques
1,2
The nurse is educating the parents of a 2-month-old infant when to contact the healthcare provider. Which statements by the parents indicate the need for further instruction? Select all that apply.
- “We will contact the doctor if our baby does not have a bowel movement each day.”
- “We will contact the doctor if our baby is vomiting.”
- “We will contact the doctor if our baby has a temperature greater than 99°F.”
- “We will contact the doctor if our baby does finish each bottle.”
- “We will contact the doctor if our baby develops a skin rash.”
1,3,4
