Jensen's Health Assessment 3rd Ed. | Chapter 26

The student nurse reports that the breath sounds of an infant are loud and harsh. How should the nurse best respond?

"Breath sounds in infants will be louder and harsher due to a thinner chest wall"

Sally, a 4-month-old infant, is brought to the clinic by her mother. The nursing assessment reveals the following: temperature 102 degrees Fahrenheit, heart rate 144, respiratory rate 36. Sally is fussy and cries intermittently; crackles are noted in the lung bases bilaterally; no outward signs of injury or illness are noted. Which question is most appropriate for the nurse to ask first?

"Has Sally been exposed to anyone who has been ill?"

A nurse is presenting a class for new parents about infant care. Which of the following positions would the nurse emphasize as important in decreasing the risk of sudden infant death syndrome?

Supine

The nurse has established an expected outcome for a hospitalized newborn, "The newborn will maintain birth weight of 6 lbs 2 oz by discharge." Which nursing action can best evaluate the outcome?

Weighing the infant on the same scale.

A nurse performs, measures, and documents the findings of the initial newborn assessment. Which data should the nurse recognize as an abnormal finding in the newborn?

Weight of 2000 g

The Moro reflex is

a response to sudden stimulation or an abrupt change in position.

During a physical examination a 4-month old baby begins to cry. Which assessment finding should the nurse expect at this time?

bulging anterior fontanelle Rationale: The anterior fontanelle may bulge when the infant cries but should go back to flat when the crying stops. If it does not, the nurse should encourage the mother to bring the infant to the health care clinic as soon as possible.

When teaching about minimizing risks of choking, the nurse would advise the parents to survey the environment

from the infant's perspective

The mother of a newborn has struggled to effectively breastfeed her daughter. The mother has received instruction from a lactation specialist on proper breastfeeding techniques, but the baby will not latch on. She has decided to bottle feed the baby at least for now. Also, when assessing the infant's musculoskeletal system, the nurse found unequal gluteal folds and limited hip abduction. Which of the following should be the priority nursing conclusion?

RC: Hip displacement

A nurse is reviewing an infant's Apgar score. Which of the following areas was assessed during the calculation of the score?

Reflex irritability Rationale: A. Appearance (skin temperature) P. Pulse G. Grimace (reflex irritability) A. Activity (muscle tone) R. Respirations

The staff educator for a pediatric unit is presenting a class to a group of new nurses. Today they are talking about emergent situations in infants. What would the staff educator identify as the most common cause of emergent situations in infants?

Respiratory decompensation

When assessing a child with respiratory distress, it is important to ask further questions. What is the priority question that the nurse needs to ask?

Has the infant been exposed to anyone with a communicable illness?

A parent tells the nurse, "Sometimes when the baby won't stop crying, I put a little bit of honey in the warm formula. He seems to like it and it soothes him." What is the primary concern with giving honey to infants?

Honey can cause infant botulism.

A new mother wants to give her baby honey. The nurse tells her that it is potentially dangerous to do this. Why is this practice potentially dangerous?

Honey is a known reservoir for the botulism bacterium

A nurse inspects the anus of a newborn. Which of the following findings should be referred immediately to a specialist?

Imperforate anus

A nurse is assessing a newborn and observes the baby's skin to be cool. The newborn has cyanotic nail beds, pallor, and a temperature of 96 degrees Fahrenheit. What would be the priority nursing diagnosis for this newborn?

Ineffective thermoregulation related to immaturity of neurologic and endocrine systems

A mother brings her 3-month-old infant to the health care clinic because she has noticed that her child has developed a sunken abdomen with prominent rib cage. That nurse recognizes the underlying case of this condition is which of the following?

Malnutrition and dehydration

The nurse is assessing a newborn infant who currently has nasal congestion and rhinorrhea. What would the nurse consider when analyzing these data?

Nasal congestion can impair oxygenation because infants are nose breathers.

The nurse is performing an eye assessment on a newborn and is unable to elicit a red reflex. What is the priority intervention that the nurse should do at this time?

Notify the physician.

During examination of a newborn, the nurse touches the upper lip so that the newborn will move the head towards the stimulated area and opens the mouth. What reflex is the nurse eliciting from this action?

Rooting Rationale: The nurse is eliciting the rooting reflex in the baby. The sucking reflex is assessed by placing the nipple in the newborn's mouth. The plantar reflex is assessed by touching the ball of the newborn's foot so that the toes will curl downwards tightly. The palmar reflex is elicited by pressing the fingers against the palmar surface of the newborn's hands from the ulnar side.

A new mother tells the nurse that the newborn has a small yellow lesion on the hard palate of the mouth and is worried about the baby's ability to suck properly. What should the nurse tell the mother about this finding?

"This is common and will disappear within the first few weeks."

A parent is changing a newborn girl's diaper prior to leaving the hospital following birth. A few drops of blood are observed in the diaper. What can the nurse tell the parent about this finding?

"This results from maternal hormones and should not be present after a few weeks." Rationale: The newborn girl may have an enlarged clitoris and labia, and the parent may notice a few drops of blood in the diaper. These findings result from lingering effects of maternal hormones and should not be present after the first few weeks of life.

The anterior fontanelle of a neonate closes between

12 and 18 months.

A clinic nurse is assessing a 6-month-old infant prior to the administration of scheduled immunizations. The nurse should anticipate that the infant's resting heart rate will be nearest to what value?

120 bpm

Place in order the sequence of cephalocaudal development that the nurse expects to find in the infant. Begin with the first development expected, sequencing to the final.

2. Lift head when prone 3. Gain complete head control 4. Sit unsupported 5. Crawl 1. Walk

The nurse is caring for the following newborns. Which newborn should the nurse refer for further evaluation?

A 12-hour Caucasian newborn with urinary meatus on the underside of the penis Rationale: Hypospadias is the abnormal placement of the urinary meatus on the underside of the penis and often requires surgical correction. The nurse should refer the 12-hour Caucasian newborn with hypospadias to a urologist. Mongolian spots, or bluish areas on the buttocks, can be an expected finding in an African American newborn. A macular stain is a capillary malformation that can appear on the nape of the neck, between the eyebrows, or on the eyelid(s). A spider nevus is a benign lesion with a spider-like appearance. Mongolian spots, macular stains, and spider nevi are normal skin variants.

The nurse is assessing a 4-month-old baby. Which observation indicates that the child is developing gross motor skills?

Absence of head lag Rationale: By 3 to 4 months of age, there is almost no head lag. The child pulls to stand by 9 months. The child sits unsupported by age 6 to 7 months. The child is able to roll from front to back by age 5 months.

The nurse is caring for a newborn after vaginal delivery. The nurse assesses a heart rate of 172 beats/min, nasal flaring, sternal retractions, cyanosis, and grunting with respirations. What intervention should the nurse anticipate?

Bag and mask or mechanical ventilation

Which action by the nurse demonstrates the correct technique of assessing for the square window sign?

Bend wrist toward ventral forearm

Which method should a nurse use when assessing respirations in a newborn?

Observe the respiratory effort for one full minute

A nurse assesses an 8-month-old infant and observes an irregular shape to the infant's head. What assessment should the nurse perform next?

Palpate anterior fontanelle

A nurse is assessing the hip and legs of a newborn. The nurse suspects congenital hip dysplasia based on which of the following?

Positive Ortolani's sign

The nurse is assessing the gestational age of a newborn and evaluating the newborn's neuromuscular maturity. Which of the following would the nurse expect to find if the newborn was premature?

Delayed arm recoil

The nurse is caring for a 2-month-old infant who has the following vital signs: temperature reading of 98.6° F (37° C); heart rate 122 bpm; respiratory rate 28 breaths per minute. The nurse should:

Do nothing, as the infant's vital signs are within normal limits.

The nurse notes that a sleeping newborn's heart rate is 102 bpm. What action should the nurse take first?

Document the heart rate Rationale: A pulse rate of 100 bpm when the infant is sleeping is considered normal and should be documented. There is no need to apply oxygen, notify the health care provider, or increase the temperature in the incubator.

A nurse assesses a newborn with bruising on the head. How should the nurse document this finding?

Ecchymoses

The nurse assesses the skin of a 2-week-old infant. For which finding should the nurse notify the health care provider?

Eight hyperpigmented macules over both legs Rationale: Hyperpigmented macules are considered Café au lait spots. If more than 6 are present, it may indicate neurofibromatosis and should be reported to the health care provider. A port-wine stain, telangiectatic nevi, and birth marks are considered normal newborn skin variations.

A mother is being educated about accidental child poisoning. What is the priority focus for the nurse to teach the mother about reducing the risk of accidentally poisoning?

Explain the importance of keeping medications and other chemicals out of the reach of children

When the nurse palpates the neck of an infant, he notices crepitus at the right clavicular area. The infant also exhibits decreased movement in the right arm. Which of the following would the nurse suspect?

Fractured clavicle

A client brings in her 5-month-old for a "stuffy nose." While the infant is being examined, the parent states, "Why does my baby still have a hard time holding his head up?" What does the nurse understand about this milestone?

The infant should be able to hold the head up without support by 4 months of age.

The nurse is performing an initial assessment of the newborn in the nursery. To assess gestational age in the newborn, what tool will she use?

The new Ballard tool

The nurse is providing discharge instructions for the parents of a newborn. Which observations by the nurse would cause concern regarding the parents' understanding of the risk factors for sudden infant death syndrome (SIDS)?(Select all that apply.)

The parent props a bottle with a rolled blanket for a feeding. The parent places the newborn on the bed in the prone position. Rationale: Assessing the risk factors for SIDS includes inquiring if the infant is sleeping on the back, asking if the parents are not propping bottles, and asking about exposure to second-hand smoke.

When performing an assessment of a 2-month-old infant, the nurse turns the baby's head to the side while the infant is supine. The arm and leg extend on the side to which the face is pointed. The contralateral arm and leg flex, forming the classic fencing position. What is the name of this reflex?

Tonic neck reflex

The first principle of child development is that it proceeds along a predictable pathway.

True