NUR 304 Exam 7

NUR 304 Exam 7
1. A 6-week-old infant grasps a rattle placed in the hand. The parent is im- pressed with this
skill. What should the nurse teach the parent about this behavior?
1
This is the palmar grasp reflex and is expected at this age.
2
This is the pincer grasp, which disappears within several months.
3
Grasping is a voluntary behavior usually observed in older infants.
4
Grasping is an atypical behavior, and further evaluation is required.
Answer
1 This is the palmar grasp reflex and is expected at this age.
The palmar grasp reflex is expected at 6 weeks of age, begins to fade at 2 months, and
disappears by 4 months. The pincer grasp is a fine motor voluntary behavior that begins around
8 months of age. Grasping is involuntary behavior; it is a reflex response that is not expected in
older infants.The palmar grasp reflex is typical, not atypical, for a 6-week-old infant.
2. 2. Place the order of blood flow from right side of heart to pulse oximetry measurement.
ORDER
a. O2 blood flow pumps from left side of heart to peripheral arteries
b. Deoxygenated blood flows to pulmonary capillaries
c. Hemoglobin saturated w/ O2 flows to pulmonary veins
d. O2 diffuses from alveoli to blood
Answer
b.Deoxygenated blood flows to pulmonary capillaries
d. O2 diffuses from alveoli to blood
c. Hemoglobin saturated w/ O2 flows to pulmonary veins
a. O2 blood flow pumps from left side of heart to peripheral art
3. The parents of a 6-month-old ask a nurse how to introduce their infant to pureed foods. How
should the nurse respond?
1
"Introduce one food at a time every 4 to 7 days."
2
"Mix the pureed food with the formula two or three times a day."
3
"Try to maintain the formula intake regardless of solid food intake."
4
"Offer pureed foods by spoon after the bottle of formula is finished."
Answer
1 "Introduce one food at a time every 4 to 7 days."
The introduction of one new food at a time permits the identification of any food allergies that
might be present; intake of multiple new foods makes identification of the causative foods more
difficult if there is a reaction. Mixing the food with formula can create feeding problems; if the
infant does not like the taste of a food, it may be associated with the formula. Formula intake
should be decreased as solid food intake increases, or the infant will be receiving excessive
calories. Although pureed foods may be offered by spoon once the formula is finished, solid
foods should be given when the infant is hungry to encourage intake.

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