The nurse is performing an assessment on a 10-week-old infant. The nurse understands that the developmental characteristic of hearing at this age is which?

Correct Answer: C

Rationale: The correct answer is option C: "The infant turns his head to the side when sound is made at the level of the ear." At 10 weeks of age, infants typically demonstrate the auditory development milestone of localizing sound by turning their head towards the direction of the sound at the level of the ear. This response indicates the infant's ability to orient towards auditory stimuli, a crucial skill for communication and safety. Option A is incorrect because responding to one's name usually occurs around 9-12 months of age, not at 10 weeks. Option B is incorrect as infants at 10 weeks are not yet able to localize sound by turning their head directly to the sound; they typically turn their head towards the general direction of the sound. Option D is incorrect as looking up or down in response to sound is not a typical auditory development milestone at this age. Understanding developmental milestones in infants is essential for nurses caring for pediatric patients. It helps them assess if the infant is progressing appropriately and allows for early identification of any potential developmental delays, enabling timely interventions and support. By knowing these milestones, nurses can tailor their care to meet the developmental needs of the child and provide appropriate education and support to the parents.

Correct Answer: A

Rationale: In the case of an infant with a history of failure to thrive (FTT) who is now gaining weight steadily, limiting fruit juice intake to no more than 4 oz/day is crucial. Infants with FTT are at risk for poor weight gain and excessive fruit juice consumption can displace more nutrient-dense foods, leading to inadequate caloric intake. Option A (4 oz/day) is the correct choice because the American Academy of Pediatrics recommends limiting fruit juice intake for infants to prevent excessive calorie intake and potential dental issues. Options B, C, and D are incorrect as they exceed the recommended daily limit for fruit juice intake in infants. Providing more than 4 oz/day of juice can lead to increased sugar consumption, which may contribute to obesity and other health concerns in infants. From an educational perspective, it is important for nurses to understand the specific dietary recommendations for infants with FTT to support their growth and development appropriately. By limiting fruit juice intake and focusing on nutrient-rich foods, nurses can help promote healthy weight gain and overall well-being in these vulnerable infants.

Correct Answer: D

Rationale: In the context of Nursing Care of Children, understanding colic is crucial for providing effective care to infants. The correct answer is D) A paroxysmal abdominal pain or cramping manifested by episodes of loud crying. This is because colic is characterized by uncontrollable crying in an otherwise healthy infant, typically starting around 2-3 weeks of age and resolving by 3-4 months. The infant may clench their fists, draw up their legs, and have a flushed face during these episodes. Option A, periods of abdominal pain resulting in weight loss, is incorrect because colic does not lead to weight loss. Option B, usually the result of poor or inadequate mothering, is a misconception and can be harmful if believed by parents. Option C, periods of abdominal pain and crying occurring in infants older than age 6 months, is incorrect because colic typically occurs in younger infants. Educationally, it is important for nursing students to understand the characteristics of colic to differentiate it from other conditions causing infant distress. By recognizing the signs and symptoms of colic, nurses can provide support and education to parents, helping them cope with this challenging but ultimately benign condition.

Correct Answer: A

Rationale: The correct answer is A) Encourage the parent to verbalize feelings. This is the best action because it demonstrates therapeutic communication, empathy, and support for the parent's emotional well-being. By encouraging the parent to express their feelings, the nurse can help validate their emotions, reduce stress, and foster a trusting relationship. Option B) Encouraging the parent not to worry so much is dismissive and does not address the parent's emotional needs or the challenges they are facing with a colicky infant. Option C) Assessing the parent for other signs of inadequate parenting is presumptive and may create unnecessary stress or guilt for the parent. It is important to approach the situation with empathy and support rather than suspicion. Option D) Reassuring the parent that colic rarely lasts past age 9 months is informative but does not address the parent's current distress or offer emotional support. It is crucial to prioritize the parent's emotional well-being and provide a supportive environment for them to express their feelings and concerns. In an educational context, this question highlights the importance of therapeutic communication skills in pediatric nursing. Nurses must be able to support and empathize with parents who may be experiencing stress or emotional challenges related to their child's health. Encouraging open communication and active listening can help build trust and rapport with parents, leading to better outcomes for both the child and the family.

Correct Answer: C

Rationale: In the context of nursing care of children, it is crucial to understand the clinical manifestations of failure to thrive (FTT) to provide appropriate care. In this scenario, the correct answer is C) Weight that is at or below the 10th percentile. This is because FTT is characterized by inadequate weight gain or inappropriate weight loss in children, leading to their weight falling below the expected range for their age. This can be a result of various factors such as inadequate caloric intake, underlying medical conditions, or poor feeding practices. Option A) Irregularity in activities of daily living is incorrect as it does not directly relate to the typical clinical manifestation of FTT, which is primarily centered around growth parameters. Option B) Preferring solid food to milk or formula is also incorrect as it may indicate a preference in food texture but is not a specific clinical manifestation of FTT. Option D) Appropriate achievement of developmental landmarks is incorrect because while FTT can impact development, the primary clinical manifestation is related to weight and growth parameters falling below expected percentiles. Educationally, understanding the signs and symptoms of FTT is essential for early identification and intervention to prevent further complications in children's health. Nurses need to be able to recognize these manifestations to collaborate with the healthcare team in developing a comprehensive care plan to address the underlying causes of FTT and promote optimal growth and development in children.