Infant
Which of the following should the nurse use to determine achievement of the expected outcome for an infant with severe diarrhea and a nursing diagnosis of Deficient fluid volume related to passage of profuse amounts of watery diarrhea? A) Moist mucous membranes. B) Passage of a soft, formed stool. C) Absence of diarrhea for a 4-hour period. D) Ability to tolerate intravenous fluids well.
A) Moist mucous membranes. Reason: The outcome of moist mucous membranes indicates adequate hydration and fluid balance, showing that the problem of fluid volume deficit has been corrected. Although a normal bowel movement, ability to tolerate intravenous fluids, and an increasing time interval between bowel movements are all positive signs, they do not specifically address the problem of deficient fluid volume.
A nurse is caring for a family whose infant has anencephaly. The most appropriate nursing intervention is to: A) help the family prepare for the infant's imminent death. B) implement measures to facilitate the attachment process. C) provide emotional support so the family can adjust to the birth of an infant with health problems. D) prepare the family for the extensive surgical procedures the infant will require.
A) help the family prepare for the infant's imminent death. Reason: Anencephaly is incompatible with life. The nurse should support family members as they prepare for the infant's imminent death. Facilitating the attachment process, helping the family to adjust to the infant's problems, and preparing the family for extensive surgical procedures are inappropriate because the infant can't survive.
A 10-month-old child with recurrent otitis media is brought to the clinic for evaluation. To help determine the cause of the child's condition, the nurse should ask the parents: A) "Does water ever get into the baby's ears during shampooing?" B) "Do you give the baby a bottle to take to bed?" C) "Have you noticed a lot of wax in the baby's ears?" D) "Can the baby combine two words when speaking?"
B) "Do you give the baby a bottle to take to bed?" Reason: In a young child, the eustachian tube is relatively short, wide, and horizontal, promoting drainage of secretions from the nasopharynx into the middle ear. Therefore, asking if the child takes a bottle to bed is appropriate because drinking while lying down may cause fluids to pool in the pharyngeal cavity, increasing the risk of otitis media. Asking if the parent noticed earwax, or cerumen, in the external ear canal is incorrect because wax doesn't promote the development of otitis media. During shampooing, water may become trapped in the external ear canal by large amounts of cerumen, possibly causing otitis external (external ear inflammation) as opposed to internal ear inflammation. Asking if the infant can combine two words is incorrect because a 10-month-old child isn't expected to do so.
Before placement of a ventriculoperitoneal shunt for hydrocephalus, an infant is irritable, lethargic, and difficult to feed. To maintain the infant's nutritional status, which of the following actions would be most appropriate? A) Feeding the infant just before doing any procedures. B) Giving the infant small, frequent feedings. C) Feeding the infant in a horizontal position. D) Scheduling the feedings for every 6 hours.
B) Giving the infant small, frequent feedings. Reason: An infant with hydrocephalus is difficult to feed because of poor sucking, lethargy, and vomiting, which are associated with increased intracranial pressure. Small, frequent feedings given at times when the infant is relaxed and calm are tolerated best. Feeding an infant before any procedure is inappropriate because the stress of the procedure may lead to vomiting. Ideally, the infant should be held in a slightly vertical position when feeding to prevent backflow of formula into the eustachian tubes and subsequent development of ear infections. Most infants are fed on demand every 3 to 4 hours.
The nurse is assessing the development of a 7-month-old. The child should be able to: A) Play pat-a-cake. B) Sit without support. C) Say two words. D) Wave bye-bye.
B) Sit without support. Reason: The majority of infants (90%) can sit without support by 7 months of age. Approximately 75% of infants at 10 months of age are able to play pat-a-cake. The ability to say two words occurs in 90% of children by age 16 months. A child typically can wave bye-bye at about 14 months of age.
A parent confides to the nurse that their 8-month-old infant is anxious. Which of the following suggestions by the nurse is most appropriate to help the mother lessen her anxiety about her infant? A) Limit holding the infant to feeding times. B) Talk quietly to the infant while he is awake. C) Play music in his room for most of the day and night. D) Have a close friend keep the infant for a few days.
B) Talk quietly to the infant while he is awake. Reason: Infants are sensitive to stress in their caretakers. The best way to handle an anxious infant is to talk quietly to him, thereby soothing the infant. Limiting holding of the infant to feeding periods interferes with meeting the infant's needs for close contact, possibly compromising his ability to develop trust. Playing music in the room for most of the day and night will make it difficult for the infant to differentiate days from nights. Having a friend take the infant for several days will not necessarily take care of the problem because when the infant returns to the mother the same behaviors will recur unless the mother makes some changes.
A 10-month-old child has cold symptoms. The mother asks how she can clear the infant's nose. Which of the following would be the nurse's best recommendation? A) Use a cool air vaporizer with plain water. B) Use saline nose drops and then a bulb syringe. C) Blow into the child's mouth to clear the infant's nose. D) Administer a nonprescription vasoconstrictive nose spray.
B) Use saline nose drops and then a bulb syringe. Reason: Although a cool air vaporizer may be recommended to humidify the environment, using saline nose drops and then a bulb syringe before meals and at nap and bed times will allow the child to breathe more easily. Saline helps to loosen secretions and keep the mucous membranes moist. The bulb syringe then gently aids in removing the loosened secretions. Blowing into the child's mouth to clear the nose introduces more organisms to the child. A nonprescription vasoconstrictive nasal spray is not recommended for infants because if the spray is used for longer than 3 days a rebound effect with increased inflammation occurs.
During assessment of a small infant admitted with a diagnosis of meningitis, the infant becomes less responsive to stimuli and exhibits bradycardia, slight hypertension, irregular respirations, and a temperature of 103.2° F (39.6° C). The infant's fontanel is more tense than at the last assessment. What should the nurse do first? A) Ask another nurse to verify the findings. B) Notify the primary care provider of the findings. C) Raise the head of the bed. D) Administer an antipyretic.
C) Raise the head of the bed. Reason: Signs such as a decrease in the level of consciousness, bradycardia, hypertension, irregular respirations, and a tense fontanel strongly suggest increased intracranial pressure. The first action should be to attempt to lower the pressure by raising the head of the bed, which should improve venous return and decrease the pressure. Asking another nurse to verify the findings is unnecessary because temperature, pulse, and respirations are fairly objective data and not subject to interpretation. Additionally, asking for verification would waste valuable time. After elevating the infant's head by raising the bed, the nurse can notify the primary care provider and administer the antipyretic.
An infant is hospitalized for treatment of inorganic failure to thrive. Which nursing action is most appropriate for this child? A) Encouraging the infant to hold a bottle B) Keeping the infant on bed rest to conserve energy C) Rotating caregivers to provide more stimulation D) Maintaining a consistent, structured environment
D) Maintaining a consistent, structured environment Reason: The nurse caring for an infant with inorganic failure to thrive should strive to maintain a consistent, structured environment because it reinforces a caring feeding environment. Encouraging the infant to hold a bottle would reinforce an uncaring feeding environment. The infant should receive social stimulation rather than be confined to bed rest. The number of caregivers should be minimized to promote consistency of care.