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 black or green."

"This is normal behavior for infants due to the immaturity of the gastrointestinal system."

"This is normal behavior for infants unless the stool passed is hard and dry."

"This indicates a blockage in the intestine and must be reported to the health care provider."

Answer and Explanation

The Correct Answer is B

A. "This is normal behavior for infants unless the stool passed is black or green.": While black or green stools may indicate potential issues, grunting and crying during bowel movements are common behaviors in infants and are not necessarily indicative of a problem.

B. "This is normal behavior for infants due to the immaturity of the gastrointestinal system.": Grunting and crying during bowel movements are typical behaviors in infants, especially during the first few months of life. This is because the infant's gastrointestinal system is still developing and they may have difficulty coordinating their muscles to pass stool smoothly.

C. "This is normal behavior for infants unless the stool passed is hard and dry.": While hard and dry stools may indicate constipation, grunting and crying during bowel movements can still be normal behaviors in infants, regardless of the consistency of the stool.

D. "This indicates a blockage in the intestine and must be reported to the health care provider.": Grunting and crying during bowel movements are not necessarily indicative of a blockage in the intestine. These behaviors are common in infants and usually resolve as the infant's gastrointestinal system matures.

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Correct Answer is B

Explanation

A. The heart triples in size over the first year of lifE. While cardiac growth occurs during infancy, the described change is not specific to a developmental milestone.

B. 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. This statement accurately describes a significant developmental milestone related to physical growth during infancy.

C. 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: This statement describes brain growth rather than a

milestone related to physical growth or development.

D. The head circumference increases rapidly during the first 6 months: the average increase is about 1 in per month: While head circumference growth is important, it does not specifically relate to the described developmental milestone of weight gain during infancy.

A. Body weight B. Skin integrity C. Respiratory rate D. Blood pressure

Correct Answer is A

Explanation

A. Body weight: Body weight is the most reliable indicator of fluid loss, as changes in weight directly reflect changes in fluid balance. Monitoring weight is essential for assessing dehydration and guiding fluid replacement therapy.

B. Skin integrity: While changes in skin turgor and skin integrity can be indicators of

dehydration, they are less reliable in infants, especially if they have certain skin conditions or are very young.

C. Respiratory ratE. Although increased respiratory rate can occur as a compensatory mechanism for metabolic acidosis associated with dehydration, it is not as reliable as changes in body weight for assessing fluid loss.

D. Blood pressurE. While blood pressure may be affected by severe dehydration, it is not as sensitive or practical as monitoring body weight for assessing fluid loss in infants.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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 developmentalmilestone occurring in infancy?

Correct Answer is B

Explanation

A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss?

Correct Answer is A

Explanation

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