Chapter 029 PS

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Chapter 29

Nursing Care of a Family With an Infant

CD PATIENT SCENARIO

CARE STUDY: AN INFANT WHO DOESN’T EAT WELL

Tina Burrows, 3 months old, is seen for a well-child checkup.

CHIEF CONCERN:

“She seems to be small and is sick all the time.”

HISTORY OF CHIEF CONCERN:

Child has had colic since birth. Parents are worried Tina is not growing as fast as she

should. Child is breastfed; parents started giving “occasional” supplemental baby fruit

and cereal 2 weeks ago. Child has vomited twice in last 2 days.

FAMILY PROFILE:

Infant's parents live with grandparents in their home. Both parents smoke. Mother works

at a fast food restaurant; father temporarily unemployed due to a motorcycle accident and

back injury. Finances are reported as “not the best,” but family has applied for financial

assistance and WIC supplements.

HISTORY OF PAST ILLNESSES:

Child has been attending a pediatric clinic for routine care since birth. Parents have kept

all appointments. Immunizations up to date. No major illnesses or hospitalizations; no

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accidental poisoning. Home family lives in is pre-1950s. Infant never observed chewing

on windowsills or other sources of paint.

PREGNANCY HISTORY:

Pregnancy not planned but not unwelcome. Parents were married 1 month before infant

was born. No complications during pregnancy except mother's weight gain was limited to

18 pounds. Birth weight: 6 pounds 15 ounces; length: 20 inches.

DAY HISTORY:

Nutrition: Child is breastfed four times during day. Mother began giving one-half jar

infant cereal for breakfast, other half for dinner; one jar fruit for lunch 2 weeks ago to try

and make child gain more weight. Two bottles (4 ounces each) of Similac with iron given

daily by husband while mother is at work.

Play: Follows moving object past midline. Listens and smiles at voices and music

although mother is concerned because she spends a lot of time staring at her hands.

Sleep: Infant is put to bed with a bottle to help her fall asleep; sleeps through night. Two

naps daily.

Growth & Development: Child bears weight when placed in standing position. Makes

cooing sounds as if trying to talk. Lifts arms to be picked up.

REVIEW OF SYSTEMS:

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Gastrointestinal: No teeth; gumline and buccal membrane pale. Cries sharply for at least

an hour each evening; pulls up legs as if she has gas pains. Bowel movements are normal;

has vomited once daily for last 2 days.

Musculoskeletal: Mother asked why child doesn’t sit yet; “Isn’t it time for her to do

that?”

PHYSICAL EXAMINATION

Weight: 5.0 kg (25%). Height: 58 cm (50%). Temperature: 98.4°F axillary

General appearance: Well-proportioned, 3-month-old girl sitting on mother's lap, sucking

thumb.

Head: Normocephalic; anterior fontanelle: 3 x 4 cm; posterior fontanelle: closed. Head

circumference: 39.8 cm. (50%)

Eyes: Red reflex; follows past midline to all fields of vision. PERLA.

Ears: Normal alignment. Tympanic membrane pink; landmarks present.

Mouth: No teeth as yet. Midline uvula present. Gag reflex intact.

Throat: Midline trachea; two lymph nodes palpable in right posterior cervical chain.

Chest: Heart rate: 110 beats per minute. No murmurs heard. Lungs: rhonchi present in all

lobes: respiratory rate 60 breaths per minute when crying.

Abdomen: Soft; liver palpable 2 cm; spleen not palpable. No masses.

Genitourinary: Bright red rash present on diaper area. No open lesions.

Neurological: Moro reflex no longer present. Patellar reflex: 2+.

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LABORATORY RESULTS:

Hemoglobin: 13.6 g/dL

Hematocrit: 40%

Tina is diagnosed as having a feeding disorder from parental overfeeding.

CARE STUDY QUESTIONS:

1. According to Erickson, what is the developmental task of the infant period?

a. Development of a sense of trust

b. Learning a sense of continuity

c. Gaining a sense of belonging

d. Developing a sense of initiative

Answer: a. A sense of trust is a sense of feeling loved and learning how to love.

2. The best way for Tina’s parents to help her complete the developmental task of the

first year is to

a. expose her to many caregivers.

b. respond to her needs consistently.

c. keep her stimulated with many toys.

d. reserve a special time each day to talk to her.

Answer: b. Having needs met consistently is a way to assure an infant those around her

are dependable and care for her.

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3. Tina’s mother tells you her daughter has spent a lot of time looking at her hands this

last month. You would explain the reason for this is most likely that

a. this may indicate the infant is near sighted.

b. the child’s hands must hurt in some way.

c. she should give the child more toys.

d. hand regard is normal for a 3-month-old.

Answer: d. “Hand regard” or inspecting hands is age-appropriate behavior for a 3-month

old.

4. Anticipatory guidance that would be good to give Tina’s parents for her 4th month

would be that

a. she will probably develop a fear of strangers.

b. she will likely turn over from front to back.

c. she will become stubborn and persistent.

d. they can expect many “blue” or moody periods.

Answer: b. Most infants turn from the front to back by 4 months and back to front by 5

months.

5. Tina has had episodes of colic since she was born. The finding in her health history

that is most indicative of colic is that she

a. cries when she is hungry.

b. has vomited for the last 2 days.

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c. has normal bowel movements.

d. stretches her legs when held upright.

Answer: c. Infants have normal bowel movements with colic, a finding that separates

colic from many other infant gastrointestinal disorders.

6. In planning care for the next month for Tina, you would want to tell her parents that

a. colic symptoms usually fade shortly after 3 months.

b. children with colic develop a “nervous bowel” by school age.

c. it was smart to strengthen feedings to help her gain weight.

d. they should put Tina to sleep on her stomach to reduce colic.

Answer: a. Colic symptoms run a limited course and generally fade by the end of the 3rd

month. Overfeeding results in vomiting and more intestinal discomfort. Infants should

sleep on their back to reduce the risk of sudden infant death syndrome.

7. Tina’s parents ask you questions about normal growth and development. By 10 months

of age, infants typically pick up small objects by

a. “hitching” them forward.

b. “scooping” them up.

c. using a thumb and finger.

d. using only a thumb.

Answer: c. A “pincer grasp” is picking up objects by a thumb and finger and is acquired

by infants at about 10 months.

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8. Tina’s mother reports Tina has a “social smile.” Infants typically develop this

a. as soon as the extrusion reflex fades.

b. at about 4 months of age.

c. when the Moro reflex fades.

d. at 6 to 8 weeks.

Answer: d. Infants return a smile when someone talks to them at 6 to 8 weeks.

9. Tina’s parents wonder why she doesn’t sit yet. Which statement best reflects average

sitting ability of infants?

a. Most sit steadily at 3 months; Tina is delayed.

b. Most do not sit well until 8 months; she is normal.

c. Sitting and the age of first tooth eruption correlate.

d. Most infants sit steadily by the end of the 4th month.

Answer: b. A major milestone of development is sitting at 8 months of age.

10. Tina is given a commercial formula with iron while her mother works. To assess her

caloric intake, you would count commercial formulas as supplying how many

calories?

a. 20 calories per ounce

b. 40 calories per ounce

c. 100 calories per ounce

d. 120 calories per ounce

Answer: a. Twenty calories per ounce simulates the number of calories in breast milk.

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11. When Tina’s parents tell you her immunizations are up to date, you would anticipate

this means she

a. began DPT immunization at 2 months.

b. is fully immunized against poliomyelitis.

c. has received a measles-mumps-rubella vaccine.

d. has received her sickle cell vaccination.

Answer: a. Diphtheria-pertussis-tetanus immunizations begin at 2 months of age;

measles-mumps-rubella is not given until 12 months. Poliomyelitis immunization is not

complete until 6 months; there is no sickle cell vaccination.

12. Tina has doubled her birth weight. You would evaluate this as

a. abnormal; most infants do this by 2 months.

b. a normal finding in most infants today.

c. abnormal; this is unusual until 7 months.

d. normal but unusual in a child with colic.

Answer: b. Most infants double their birth weight by 4 to 5 months. A mark of colic is

the child’s weight gain is normal despite the abdominal discomfort.

13. Tina receives a combination of breast milk, commercial formula, and solid food

daily. Advice you would want to give her mother regarding this would be that

a. most nutritionists recommend infants do not receive solid food until 4 to 6 months.

b. giving the solid food is more important than formula as it contains more protein.

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c. as long as Tina is gaining weight on the feeding pattern, it must be good for her.

d. Tina is too old for breast milk; the mother should eliminate feedings of that.

Answer: a. Infants do not need solid food until 4 to 6 months; they should drink breast

milk or a commercial formula until then.

14. Tina’s mother is happy to learn it is too early to give Tina solid food because she has

noticed Tina consistently pushes all food out of her mouth with her tongue as if she

dislikes everything. You would explain to the mother that

a. infants as young as Tina are too young to have food preferences.

b. she must be influencing the child by the way she presents the food.

c. it sounds as if she is describing an extrusion reflex, not a food dislike.

d. she should write the baby food manufacturer and tell them it tastes bad.

Answer: c. Infants have an extrusion reflex that makes them push food out of their mouth

until 4 to 5 months of age.

15. Tina has no teeth yet. As she is 3 months old, you would assess this as

a. unusual as the front central incisors usually erupt by 3 months.

b. normal; a child’s first tooth doesn’t usually erupt until 6 months.

c. abnormal; Tina must have suffered a calcium deficiency in utero.

d. usual although she can expect the first lateral molar to erupt soon.

Answer: b. The first tooth to erupt (a front central incisor) doesn’t usually appear until 6

months of age.

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16. The total number of temporary teeth that children develop is

a. 10.

b. 20.

c. 24.

d. 30.

Answer: b. There are 20 temporary or deciduous teeth.

17. A phenomenon that typically occurs at 8 months of age that you would want to

caution Tina’s parents will occur is

a. fear of strangers.

b. fear of falling.

c. fear of the dark.

d. excessive babbling.

Answer: a. Fear of strangers, or reluctance to go to a person a child does not know,

typically occurs at about 8 months so it is called 8th month anxiety.

18. You note that Tina’s father puts her to bed at night with a bottle of formula. You

would advise him that

a. as he knows, this is often an effective technique for inducing sleep.

b. baby formula that remains in the mouth will cause cavities in early teeth.

c. there’s no harm in doing this although he should think about holding her.

d. he should be certain to use a plastic bottle to avoid broken glass in the crib.

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Answer: b. Formula has a high sugar content so it can lead to early cavities of bottom

teeth, termed baby-bottle syndrome.

19. Tina sucks her thumb. Advice you would give her parents about this is that

a. thumb sucking leads to permanent tooth and palate deformities.

b. Tina is telling them she does not have enough protein in her diet.

c. many infants enjoy thumb sucking; it does not have long-term effects.

d. if she puts a disagreeable tasting food on her thumb, she can stop this.

Answer: c. Thumb sucking or oral stimulation is a natural response of infants and, if

discontinued by school age, does not cause jaw or teeth deformities.

20. What would be an important child-proofing measure you would stress with Tina’s

parents?

a. They should monitor the size of toys to help Tina from aspirating a small one.

b. Teach her to blow out candles so she learns early that fire is hot and could burn.

c. Leave the infant in the car if shopping to avoid contracting infections from crowds.

d. Pad her crib with soft pillows to prevent her injuring her arms or legs against the bars.

Answer: a. Any toy under the size of a toilet paper tube is a size that can be aspirated;

parents shouldn’t teach fire is fun by blowing out candles; children should not be left in

cars because of the danger of heat stroke; soft pillows could lead to suffocation.

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