The nurse is assessing a 4-month-old boy during a scheduled visit. Which findings might suggest a developmental problem?

The child does not vocally respond to voices.

The child never squeals or yells.

The child does not babble.

The child does not say dada or mama.

Answer and Explanation

The Correct Answer is C

A. The child does not vocally respond to voices: While vocal responsiveness is an important aspect of development, it may vary among infants and is not necessarily indicative of a developmental problem at 4 months.

B. The child never squeals or yells: Squealing and yelling are vocalizations that infants may or may not exhibit at this age, and their absence alone may not necessarily indicate a developmental problem.

C. The child does not babblE. Babbling, which typically begins around 4 to 6 months of age, involves the repetition of consonant-vowel combinations (e.g., "bababa"). The absence of babbling by 4 months may suggest a delay in language development and could be a potential sign of a developmental problem.

D. The child does not say dada or mamA. Infants may begin to associate "dada" or "mama" with specific caregivers, but this typically occurs later, closer to 6 to 9 months of age. The absence of this behavior at 4 months may not necessarily indicate a developmental problem.

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Correct Answer is A

Explanation

A. "I will give him a pacifier during feeding time.": Giving a pacifier during feeding time may interfere with the infant's ability to coordinate sucking, swallowing, and breathing, especially if

they are receiving nutrition through a nasogastric tube. This response indicates a need for further teaching because pacifiers during feeding time could potentially disrupt the infant's feeding

pattern and may not be appropriate in this situation.

B. "We need to make sure he doesn't lose the desire to eat by mouth.": This response

demonstrates an understanding of the importance of maintaining the infant's oral feeding skills and indicates appropriate knowledge about promoting oral feeding while using a nasogastric

tube.

C. "We need to keep feeding time very quiet.": Keeping feeding time quiet can help reduce distractions and promote a calm environment, which may enhance feeding tolerance for the infant. This response reflects an understanding of strategies to facilitate feeding.

D. "Sucking produces saliva, which aids in digestion.": This response demonstrates knowledge about the benefits of sucking and saliva production during feeding, indicating an understanding of the infant's physiological needs during feeding.

A. Place the crushed tablet in the infant's formula. B. Mix the crushed tablet with the infant's cereal. C. Mix the crushed tablet with a small amount of applesauce. D. Crushed tablets should only be mixed with water.

Correct Answer is C

Explanation

A. Place the crushed tablet in the infant's formulA. Mixing crushed tablets with formula may alter the taste or consistency of the formula, making it less palatable for the infant.

B. Mix the crushed tablet with the infant's cereal: Mixing crushed tablets with cereal may also alter the taste and texture of the cereal, potentially making it unappealing to the infant.

C. Mix the crushed tablet with a small amount of applesaucE. Mixing crushed tablets with a small amount of applesauce is a common method for administering medication to infants and

toddlers. The applesauce helps mask the taste and texture of the crushed tablet, making it easier for the child to swallow.

D. Crushed tablets should only be mixed with water: While water can be used to administer crushed tablets, mixing them with water alone may not effectively mask the taste or texture of the medication, making it less likely that the child will swallow it. Mixing with a food like applesauce is often more palatable for young children.

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The nurse is assessing a 4-month-old boy during a scheduled visit. Which findings might suggest a developmental problem?

Nursing Test Bank

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