PassPoint - Infant

When reinforcing education with parents of an infant newly diagnosed with diabetes insipidus, which statement by the parent indicates an appropriate understanding of this condition? 1. "When my infant stabilizes, I won't have to worry about giving hormone medication." 2. "I don't have to measure the amount of fluid intake that I give my infant." 3. "I realize that treatment for diabetes insipidus is lifelong." 4. "My infant will outgrow this condition."

Correct response: "I realize that treatment for diabetes insipidus is lifelong." Explanation: Diabetes insipidus requires lifelong treatment. The amount of fluid intake is important and must be measured with the infant's output to monitor the medication regimen. The infant won't outgrow this condition.

The nurse is teaching circumcision care to a mother before discharge. Which statement by the mother indicates that teaching was successful? 1. "I must change my son's diaper at least every 2 hours." 2. "I should reapply fresh petrolatum gauze after each diaper change." 3. "I should wash the penis with warm soap and water." 4. "I can use premoistened towelettes to clean the penis."

Correct response: "I should reapply fresh petrolatum gauze after each diaper change." Explanation: The mother's verbalization of understanding that fresh petrolatum gauze should be applied after each diaper change indicates that teaching was successful. The mother should change the diaper at least every 4 hours and clean the penis with warm water, not soap and water, until the circumcision is healed. Soap can be used after the circumcision has healed. The mother should avoid using premoistened towelettes to clean the penis because they contain alcohol, which can cause discomfort and delay healing.

A parent is taught to administer digoxin to her 6-month-old infant at home. Which statement by the parent indicates the need for additional education? 1. "I'll count the baby's pulse before every dose." 2. "I'll make sure the pulse is regular before every dose." 3. "I'll measure the dose carefully." 4. "I'll withhold the medication if the pulse is below 60."

Correct response: "I'll withhold the medication if the pulse is below 60." Explanation: A pulse rate under 60 beats/minute is an indication for withholding digoxin from an adult. Withholding digoxin from an infant is appropriate if the infant's pulse is under 90 beats/minute. The pulse rate must be counted before each dose of digoxin is given to an infant. An irregular pulse may be a sign of digoxin toxicity; if this occurs, the health care provider should be consulted before the drug is given. The dose must be measured carefully to decrease the risk of toxicity.

After explaining the causes of hypothyroidism to the parents of a newly diagnosed infant, the nurse should recognize that education needs to be reinforced when which question is asked? 1. "So, hypothyroidism can be only temporary, right?" 2. "Are you saying that hypothyroidism is caused by a problem in the way the thyroid gland develops?" 3. "Do you mean that hypothyroidism may be caused by a problem in the way the body makes thyroxine?" 4. "So, hypothyroidism can be treated by exposing our baby to a special light, right?"

Correct response: "So, hypothyroidism can be treated by exposing our baby to a special light, right?" Explanation: Congenital hypothyroidism can be permanent or transient and may result from a defective thyroid gland or an enzymatic defect in thyroxine synthesis. Phototherapy is not used to treat physiologic jaundice and indicates that the parents need more information.

The nurse has restrained an infant. Which actions by the nurse are indicated? Select all that apply. 1. Document the reason for use and effectiveness of the restraint. 2. Inspect the skin for areas of pressure. 3. Reapply the restraint to cover the hip to 1 inch above the umbilicus. 4. Loosen the restraint so the infant can move from side to side. 5. Secure the ties for quick release. 6. Tie the ends to the side rails of the crib.

Correct response: 1. Document the reason for use and effectiveness of the restraint. 2. Inspect the skin for areas of pressure. 5. Secure the ties for quick release. Explanation: Using restraints requires a primary care provider's prescription; the nurse should document the reason for use and effectiveness of the restraint. The nurse should also inspect the skin for areas of pressure caused by the restraint and remove the restraint periodically to provide skin care and range of motion. The ties should be secured so they can be released quickly if needed; the ties should be fastened to the bed springs, not the rails of the crib or the mattress. The belt restraint is positioned correctly; the restraint will limit the infant's movement yet allow for changing the diaper. The restraint should limit the infant's movement and not enable the infant to move from side to side.

A 5-month-old infant with an upper respiratory infection is brought to the clinic. The mother reports that the infant weighed 7 lb (3.2 kg) at birth. Based on the nurse's knowledge of infant weight gain, which current weight would be within the normal range for this infant? 1. 14 lb (6.4 kg) 2. 21 lb (9.5 kg) 3. 10.5 lb (4.8 kg) 4. 17.5 lb (7.9 kg)

Correct response: 14 lb (6.4 kg) Explanation: Birth weight typically doubles by age 5 months and triples by age 12 months. Therefore, an infant who weighed 7 lb (3.2 kg) at birth should weigh 14 lb (6.4 kg) at age 5 months.

Which of the following is the recommended immunization schedule for diphtheria, tetanus, acellular pertussis (DTaP)? 1. Birth, 2 months, 6 months, 15 to 18 months, and 10 to 12 years 2. 1 month, 2 months, 6 months, 15 to 18 months, and 4 to 6 years 3. 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years 4. Birth, 3 months, 6 months, 12 months, and 4 to 6 years

Correct response: 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years Explanation: According to the American Academy of Pediatrics, the DTaP vaccine should be administered at 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years (before the start of school). The other options are incorrect.

The nurse is preparing to feed the infant. Which actions by the infant indicate readiness to feed? Select all that apply. 1. burping 2. hand to mouth 3. lies quietly awake 4. rooting 5. mouthing

Correct response: 2. hand to mouth 4. rooting 5. mouthing Explanation: Readiness to feed indicators include the infant making hand to mouth and hand to hand movements, sucking motions, rooting, and mouthing. Burping is an indicator that the infants attempt to clear gas. Lying quietly with eyes open is an alert behavior, indicating normal infant reactivity.

The nurse is caring for a neonate with congenital clubfoot. The child has a cast to correct the defect. Before discharge, what should the nurse tell the parents? 1. The cast will be removed in 6 weeks. 2. A new cast is needed every 1 to 2 weeks. 3. A short leg cast is applied when the baby is ready to walk. 4. The cast will be removed when the baby begins to crawl.

Correct response: A new cast is needed every 1 to 2 weeks. Explanation: Because a neonate grows so quickly, the cast may need to be changed as often as every 1 to 2 weeks. A cast for congenital clubfoot isn't left on for 6 weeks because of the rapid rate of the infant's growth. By the time a baby is crawling or ready to walk, the final cast has long since been removed. After the cast is permanently removed, the baby may wear a Denis Browne splint until he's 1 year old.

Which action should the nurse include in the plan of care for a 2-month-old infant with heart failure? 1. Allow the infant to rest before feeding. 2. Bathe the infant and administer medications before feeding. 3. Weigh and bathe the infant before feeding. 4. Feed the infant when he cries.

Correct response: Allow the infant to rest before feeding. Explanation: Because feeding requires so much energy, an infant with heart failure should rest before feeding. Bathing and weighing the infant and administering medications should be scheduled around feedings. An infant expends energy when crying; therefore, it's best if the infant doesn't cry.

An infant, age 3 months, undergoes surgical repair of a cleft lip. After surgery, the nurse should use which equipment to feed the infant? 1. Single-hole nipple 2. Plastic spoon 3. Paper straw 4. Bulb syringe with tubing

Correct response: Bulb syringe with tubing Explanation: An infant with a surgically repaired cleft lip must be fed with a bulb syringe with tubing or Breck feeder to prevent sucking or suture line trauma. The other options wouldn't prevent these actions.

The nurse must obtain data on a 10-month-old. The child is sitting on the parent's lap and appears to be afraid of the nurse and of what might happen next. Which initial actions by the nurse would be best? 1. Initiate a game using stuffed animals. 2. Ask the parent to place the child on the examination table. 3. Talk softly to the child while taking them from the parent. 4. Undress the child while the parent watches.

Correct response: Initiate a game using stuffed animals. Explanation: It is best to gain the trust of the infant first before beginning the assessment. A 10-month-old infant is typically afraid of health care providers and will want to cling to the parent. One way to decrease anxiety and gain the infant's trust is to engage in age-appropriate play. Placing the infant on the examination table will cause the infant to want to return to the parent. Taking the infant will cause separation anxiety or fear. The parent is the best person to undress the infant to decrease anxiety.

A nurse is reinforcing education with a parent on how to reduce the baby's risk of developing otitis media. Which instruction should the nurse be sure is included in the teaching plan? 1. Administer antibiotics whenever the baby has a cold. 2. Place the baby in an upright position when giving a bottle. 3. Avoid getting the ears wet while bathing or swimming. 4. Clean the external ear canal daily.

Correct response: Place the baby in an upright position when giving a bottle. Explanation: Feeding a baby in an upright position reduces the pooling of formula in the nasopharynx. Formula provides a good medium for the growth of bacteria, which can travel easily through the short, horizontal Eustachian tubes. The other interventions do not reduce the risk of a baby developing otitis media.

The nurse is caring for a 6-week-old infant with laboratory results indicating fluid and electrolyte imbalance. Which nursing consideration is most important? 1. The infant has a lower percentage of body water than an adult. 2. The infant has a lower daily fluid requirement than an adult. 3. The infant has a more rapid respiratory rate than an adult. 4. The infant has immature kidney function.

Correct response: The infant has immature kidney function. Explanation: Because of immature kidneys, an infant's glomerular filtration and absorption are inadequate, not reaching adult levels until age 1 to 2 years. An infant has a greater percentage of body water and higher daily fluid requirements than an adult. Although the infant's respiratory rate is higher, causing insensible water loss, immature kidney function is more responsible for fluid imbalance in an infant.

The nurse is gathering data on a 1-month-old infant. Which data obtained by the parents indicate the infant may have a cardiac defect? 1. The infant is gaining weight. 2. The infant has been hyperactive. 3. The infant is not taking formula well. 4. The infant has pink, mucous membranes.

Correct response: The infant is not taking formula well. Explanation: Infants and children with heart defects tend to have poor nutritional intake and weight loss, indicating poor cardiac output, heart failure, or hypoxemia. The child appears lethargic or tired because of the heart failure or hypoxia. Gray, pale, or mottled skin may indicate hypoxia or poor cardiac output. Pink, moist mucous membranes are normal.

A nurse is reinforcing education for parents of an infant with congenital hypothyroidism. Which statement should be included? 1. A large goiter in a neonate does not present a problem. 2. Preterm neonates usually are not affected by hypothyroidism. 3. Usually, the neonate exhibits obvious signs of hypothyroidism. 4. The severity of the disorder depends on the amount of thyroid tissue present.

Correct response: The severity of the disorder depends on the amount of thyroid tissue present. Explanation: The severity of hypothyroidism depends on the amount of thyroid tissue present. The more thyroid tissue present, the less severe the disorder. Usually, the neonate does not exhibit obvious signs of the disorder because of maternal circulation. A large goiter in a neonate could possibly occlude the airway and lead to obstruction. Preterm neonates are usually affected by hypothyroidism as a result of hypothalamic and pituitary immaturity.

When administering an oral medication to an infant, the nurse should take which action to minimize the risk of aspiration? 1. Administering the oral medication as quickly as possible 2. Placing the medication in the infant's formula bottle 3. Keeping the infant upright with the nasal passages blocked 4. Using an oral syringe to place the medication beside the tongue

Correct response: Using an oral syringe to place the medication beside the tongue Explanation: When administering an oral medication to an infant, using an oral syringe is the best way to prevent aspiration because it allows controlled administration of a small amount of medication. Administering the medication too quickly could cause aspiration. Putting the drug in a bottle of formula isn't preferred because the infant may not take the entire dose of medication and because the contents of the bottle could interfere with drug absorption or action. Blocking the nasal passages could cause aspiration.

The nurse must administer a liquid medication to an infant. Which step should the nurse take first? 1. Hold the infant securely in the crook of her arm and raise the infant's head to about a 45-degree angle. 2. Place the dropper at the corner of the infant's mouth so the drug runs into the pocket between the cheek and gum. 3. Identify the infant by checking the armband. 4. Verify the physician's order.

Correct response: Verify the physician's order. Explanation: The nurse should first verify the physician's order. Next, the nurse should make sure she has the right drug, dose, route, and time. She should then make sure she has the right client by checking the infant's armband. Next, the nurse should hold the infant securely in the crook of her arm and raise the infant's head to about a 45-degree angle. Then, the nurse should place the dropper at the corner of the infant's mouth so the drug runs into the pocket between the infant's cheek and gum. Doing so keeps him from spitting out the drug and reduces the risk of aspiration.

The parents of an infant diagnosed with hypothyroidism have been taught to count the infant's pulse. Which intervention should be reinforced in case a high pulse rate is obtained? 1. Allow the infant to take a nap and then give the medication. 2. Withhold the medication and give a double dose the next day. 3. Withhold the medication and call the health care provider. 4. Give the medication and then consult the health care provider.

Correct response: Withhold the medication and call the health care provider. Explanation: If parents have been taught to count the pulse of an infant diagnosed with hypothyroidism, they should be instructed to withhold the dose and consult their health care provider if the pulse rate is above a certain value.

The nurse is caring for a neonate with esophageal atresia. Which data finding indicates that the neonate needs suctioning? 1. cyanosis of the skin 2. reduced gag reflex 3. inadequate swallow reflex 4. reduced saliva production

Correct response: cyanosis of the skin Explanation: Cyanosis occurs when fluid from the blind pouch is aspirated into the trachea, requiring suctioning. Increased saliva production is common, along with choking, coughing, and sneezing. The ability to swallow is not affected by this disorder.

A 1-month-old infant is admitted to the pediatric unit and diagnosed with bacterial meningitis. Which findings by the nurse support the diagnosis? 1. hemorrhagic rash, first appearing as petechiae 2. photophobia, diarrhea, increased appetite 3. fever, change in feeding pattern, vomiting, or diarrhea 4. fever, lethargy, and purpura or large necrotic patches

Correct response: fever, change in feeding pattern, vomiting, or diarrhea Explanation: Fever, change in feeding patterns, vomiting, and diarrhea are commonly observed in children with bacterial meningitis. Hemorrhagic rashes, petechiae, photophobia, fever, lethargy, and purpura are common manifestations in older children with meningitis.

While caring for a 2-day-old neonate, a nurse notices the left side of the neonate reddens for 2 to 3 minutes. The nurse interprets this as suggestive of what finding? 1. contact dermatitis 2. environmental conditions 3. harlequin color change 4. tet spells

Correct response: harlequin color change Explanation: Harlequin color change is a benign disorder related to the immaturity of the hypothalamic centers that control the tone of peripheral blood vessels. A newborn who has been lying on its side may appear reddened on the dependent side. The color fades on position change. Contact dermatitis isn't short-lived. Changes in environmental conditions can cause diffuse bilateral mottling of the skin. Tet spells are associated with tetralogy of Fallot and cause cyanotic changes.

Which intervention should be included in the care plan for children with an increased risk of sudden infant death syndrome (SIDS)? 1. pulmonary function testing at regular intervals 2. home apnea monitoring 3. pulse oximetry while sleeping 4. chest x-ray at age 1 month

Correct response: home apnea monitoring Explanation: A home apnea monitor is recommended for infants with an increased risk of SIDS. Diagnostic tests, such as pulmonary function tests, pulse oximetry, and chest x-rays, can't diagnose the risk of surviving or dying from SIDS.

When gathering data from a neonate, the nurse notes visible peristaltic waves across the epigastrium. Which condition should the nurse suspect in this neonate? 1. hypertrophic pyloric stenosis 2. imperforate anus 3. intussusception 4. short-gut syndrome

Correct response: hypertrophic pyloric stenosis Explanation: The diagnosis of pyloric stenosis can be established from a finding of hypertrophic pyloric stenosis. Imperforate anus, intussusception, and short-gut syndrome are diagnosed by other symptoms.

The nurse is monitoring an infant with bronchiolitis for dehydration. What intervention is the highest priority? 1. measuring intake and output 2. checking blood levels every 4 hours 3. collecting a urinalysis every 8 hours 4. weighing each diaper

Correct response: measuring intake and output Explanation: Accurate measurement of intake and output is essential to assess for dehydration. Blood levels may be obtained daily or every other day. A urinalysis every 8 hours is not necessary. Urine-specific gravities are recommended, but can be obtained with diaper changes. Weighing diapers is a way of measuring output only.

After an infant with a cleft lip has surgical repair and heals, the parents can expect to see which result? 1. misaligned teeth (malocclusion) 2. a larger upper lip 3. distortion of the jaw 4. minimal scarring

Correct response: minimal scarring Explanation: If there is no trauma or infection to the site, healing occurs with little scar formation. There may be some inflammation right after surgery, but after healing, the lip is a normal size. No jaw malformation occurs with cleft lip repair

When collecting data on a neonate for signs of diabetes insipidus, a nurse should recognize which symptom as a sign of this disorder? 1. hyponatremia 2. jaundice 3. polyuria and polydipsia 4. hypochloremia

Correct response: polyuria and polydipsia Explanation: The cardinal signs of diabetes insipidus are polyuria and polydipsia. Hypernatremia, not hyponatremia, occurs with diabetes insipidus. Jaundice occurs because of abnormal bilirubin metabolism, not diabetes insipidus. Hyperchloremia, not hypochloremia, occurs with diabetes insipidus.

Which developmental milestone would the nurse expect an 11-month-old infant to have achieved? 1. sitting independently 2. walking independently 3. building a tower of four cubes 4. turning a doorknob

Correct response: sitting independently Explanation: Infants typically sit independently, without support, by age 8 months. Walking independently may be accomplished as late as age 15 months and still be within the normal range. Few infants walk independently by age 11 months. Building a tower of three or four blocks is a milestone of an 18-month-old. Turning a doorknob is a milestone of a 24-month-old.

Which finding would concern the nurse who's caring for an infant after a right femoral cardiac catheterization? 1. weak right dorsalis pedis pulse 2. elevated temperature 3. decreased urine output 4. slight bloody drainage around catheterization site dressing

Correct response: weak right dorsalis pedis pulse Explanation: The pulse below the catheterization site should be strong and equal to the unaffected extremity. A weakened pulse may indicate vessel obstruction or perfusion problems. Elevated temperature and decreased urine output are relatively normal findings after catheterization and may be the result of decreased oral fluids. A small amount of bloody drainage is normal; however, the site must be assessed frequently for increased bleeding.

The nurse observes the primitive reflexes of a 1-month-old infant. Which of the reflexes shown in photos below should not be present after the age of 2 months?

Explanation: Option 4 shows the tonic neck reflex. Persistence of this reflex beyond 2 months suggests asymmetric central nervous system development. Option 1 shows the palmer grasp reflex. This reflex disappears around age 3 to 4 months. Option 2 shows the plantar grasp reflex. This reflex disappears at age 6 to 8 months. Option 3 shows the Moro reflex. This reflex disappears around age 4 months.

When presenting an informational series on infant safety, which appropriate development milestone for the 4-month-old infant would the nurse stress could jeopardize the infant's safety? 1. responds readily to sound 2. grabs feet and pulls to the mouth 3. turns from abdomen to back 4. drops objects to pick up another one

Correct response: turns from abdomen to back Explanation: The ability to turn from abdomen to back puts the infant at risk for falling: parents must be careful not to leave the infant unattended with the crib's side rails down, on the sofa, or on the changing diaper table. The other three responses are not additional risks for the infant.

Four children, each 6 months of age, arrive at the clinic for diphtheria-pertussis-tetanus (DPT) immunization. Which child can safely be immunized at this time? 1. the child with a temperature of 103° F (39.4° C) 2. the child with a runny nose and cough 3. the child taking prednisone for the treatment of leukemia 4. the child with difficulty breathing after the last immunization

Correct response: the child with a runny nose and cough Explanation: Children with cold symptoms can safely receive DPT immunization. Children with a temperature more than 102° F (38.9° C), serious reactions to previous immunizations, or those receiving immunosuppressive therapy shouldn't receive DPT immunization.

If an infant's I.V. access site is in an extremity, the nurse should: 1. use a padded board to secure the extremity. 2. restrain all four extremities. 3. restrain the extremity to the bed's side rail. 4. allow the extremity to be loose.

Correct response: use a padded board to secure the extremity. Explanation: A padded board is adequate to secure the extremity. Restraining all four extremities can be harmful and uncomfortable for the child. Restraining the extremity to the bed's side rail limits the child's movement; the child may bang against the rail and cause injury. Allowing the extremity to be loose increases the risk that the I.V. will infiltrate or be dislodged by the infant.

Which data collection finding would lead the nurse to suspect dehydration in a preterm neonate? 1. Bulging fontanels 2. Excessive weight gain 3. Urine specific gravity below 1.012 4. Urine output below 1 ml/hour

Correct response: Urine output below 1 ml/hour Explanation: Urine output below 1 ml/hour is a sign of dehydration. Other signs of dehydration include depressed fontanels, excessive weight loss, decreased skin turgor, dry mucous membranes, and urine specific gravity above 1.012.

The nurse is caring for a 10-month old infant. What behavioral responses to pain does the nurse anticipate observing? 1. localized withdrawal and resistance of the entire body 2. passive resistance, clenching fists, and holding body rigid 3. reflex withdrawal to stimulus and facial grimacing 4. low frustration level and striking out physically

Correct response: reflex withdrawal to stimulus and facial grimacing Explanation: Infants younger than age 1 become irritable and exhibit reflex withdrawal to the painful stimulus. Facial grimacing also occurs. Localized withdrawal is experienced by toddlers ages 1 to 3 in response to pain. The nurse would observe passive resistance in school-age children. Preschoolers show a low frustration level and strike out physically.

A mother infected with human immunodeficiency virus (HIV) asks about breast-feeding her infant. Which response would be best? 1. "It is not advisable to breast-feed if you have HIV." 2. "Breast-feeding is safe if you have HIV." 3. "You can breast-feed your infant only if you are taking zidovudine." 4. "It's best to supplement breast-feeding with formula to reduce exposure to HIV."

Correct response: "It is not advisable to breast-feed if you have HIV." Explanation: Mothers infected with HIV shouldn't breast-feed because the virus has been isolated in breast milk and can be transmitted to the infant. Taking zidovudine doesn't prevent transmission of the virus in breast milk, and supplementing breast-feeding with formula wouldn't reduce exposure of the infant to HIV in breast milk.

The nurse is reinforcing education with parents about therapeutic management of their neonate diagnosed with congenital hypothyroidism. Which response by a parent would indicate the need for further education? 1. "My baby will need regular measurements of his thyroxine levels." 2. "Treatment involves lifelong thyroid hormone replacement therapy." 3. "Treatment should begin as soon as possible after diagnosis is made." 4. "As my baby grows, his thyroid gland will mature and he won't need medications."

Correct response: "As my baby grows, his thyroid gland will mature and he won't need medications." Explanation: Treatment involves lifelong thyroid hormone replacement therapy that begins as soon as possible after diagnosis. The goal of treatment is to abolish all signs of hypothyroidism and to reestablish normal physical and mental development. The drug of choice is synthetic levothyroxine. Regular measurements of thyroxine levels are important in ensuring optimal treatment.

Which sexually transmitted disease is preventable through infant vaccination? 1. Syphilis 2. Gonorrhea 3. Chlamydia 4. Hepatitis B

Correct response: Hepatitis B Explanation: The hepatitis B vaccine is given by the I.M. route at birth or before hospital discharge, at ages 1 to 4 months, and again at ages 6 to 18 months for a total of three doses. Vaccines aren't currently available to prevent syphilis, gonorrhea, or chlamydia.

A mother is concerned that she might be spoiling her 2-month-old daughter by picking her up each time she cries. Which suggestion should the nurse offer? 1. "If the baby's diaper is dry when she's crying, leave her alone and she'll fall asleep." 2. "Continue to pick her up when she cries because young infants need cuddling and holding to meet their needs." 3. "Leave your baby alone for 10 minutes. If she hasn't stopped crying by then, pick her up." 4. "Crying at this age indicates hunger. Try feeding her when she cries."

Correct response: "Continue to pick her up when she cries because young infants need cuddling and holding to meet their needs." Explanation: The nurse should advise the mother to continue to pick the infant up when she cries because a young infant needs to be cuddled and held when crying. Because the infant's cognitive development isn't advanced enough for her to associate crying with getting attention, it would be difficult to spoil her at this age. Even if her diaper is dry, a gentle touch may be necessary until she falls asleep. Crying for 10 minutes wears an infant out; ignoring crying can make the infant mistrust caregivers and the environment. Infants cry for many reasons, not just when hungry.

An infant is brought to the emergency department and pronounced dead with the preliminary finding of sudden infant death syndrome (SIDS). Which question to the parents is most appropriate? 1. "Did you hear the infant cry out?" 2. "Was the infant's head buried in a blanket?" 3. "Were any of the siblings jealous of the new baby?" 4. "How did the infant look when you found him?"

Correct response: "How did the infant look when you found him?" Explanation: During the initial history in the emergency department, only factual questions should be asked of the parents whose child has died of SIDS. The other questions imply blame, guilt, or neglect.

A nurse is teaching the parents of an infant with clubfeet about cast care. Which statement by the father indicates the need for further teaching? 1. "We'll have to bring our baby back every week or two for cast changes." 2. "I know I will have to be careful when changing his diapers." 3. "We will have to be careful how we hold our baby." 4. "Immunizations will have to be delayed until the casts come off."

Correct response: "Immunizations will have to be delayed until the casts come off." Explanation: The father's statement about delaying immunizations indicates the need for further teaching. Immunizations can be administered in the thighs because the casts cover only the lower legs and feet. The other responses are correct statements.

For the last 6 days, a 7-month-old infant has been receiving amoxicillin trihydrate to treat an ear infection. Now the parents report redness in the diaper area and small, red patches on the infant's inner thighs and buttocks. After diagnosing Candida albicans, the physician prescribes topical nystatin to be applied to the perineum four times daily. Medication teaching should include which instruction? 1. "Discontinue amoxicillin until the diaper area is no longer red." 2. "Avoid using super absorbent disposable diapers." 3. "Inspect your infant's mouth for white patches." 4. "Switch your infant to a soy-based formula."

Correct response: "Inspect your infant's mouth for white patches." Explanation: The nurse should instruct the parents to inspect the infant's mouth for white patches. Signs of thrush, these patches are common in children with C. albicans infections and should be reported to the physician. The parents shouldn't discontinue amoxicillin; to treat an ear infection effectively, this drug must be administered for at least 10 days. The parents should use, not avoid, superabsorbent diapers because they help keep the diaper area dry—especially if this area is red and irritated. Changing the infant's formula isn't necessary because the diaper irritation probably results from amoxicillin therapy.

After the birth of her first neonate, a mother asks the nurse about the reddened areas ("stork bites") at the nape of the neonate's neck. How should the nurse respond? 1. "They're normal and will disappear as the baby's skin thickens." 2. "They're a common congenital abnormality." 3. "They commonly result from a traumatic birth." 4. "They're caused by a blockage in the apocrine glands."

Correct response: "They're normal and will disappear as the baby's skin thickens." Explanation: Capillary hemangioma ("stork bites") may appear on the neonate's upper eyelids, the bridge of the nose, or the nape of the neck. They result from vascular congestion and disappear as the skin thickens. They aren't associated with congenital abnormalities, traumatic birth, or blocked apocrine glands.

A nurse is reinforcing education for the parents of a 10-month-old infant on the correct method for instilling eardrops prescribed for the infant when discharged. Which statement by the parents indicates understanding? 1. "We should pull the earlobe upward." 2. "We should pull the earlobe up and back." 3. "We should pull the earlobe down and back." 4. "We should pull the earlobe down and forward."

Correct response: "We should pull the earlobe down and back." Explanation: For infants, the parents should understand that they should gently pull the earlobe down and back to visualize the external auditory canal. For children older than age 3 and for adults, the earlobe is gently pulled slightly up and back.

A nurse is reinforcing education with parents about the nutritional needs of their full-term infant, age 2 months, who is breastfeeding. Which response shows that the parents understand their infant's dietary needs? 1. "We won't start any solid foods now." 2. "We'll start the baby on skim milk." 3. "We'll introduce cereal into the diet now." 4. "We should add new fruits to the diet one at a time."

Correct response: "We won't start any solid foods now." Explanation: Because breast milk provides all of the nutrients that a full-term infant needs for the first 6 months, the parents should not introduce solid foods into the infant's diet at this time. Before age 6 months, an infant's GI tract cannot tolerate solid foods such as vegetables and fruit. Cereal may be introduced at 4 to 6 months of age. Parents should not provide skim milk to a child younger than age 2 because it does not have sufficient fat for infant growth.

A mother and grandmother bring a 3-month-old infant to the well-baby clinic for a routine checkup. As the nurse weighs the infant, the grandmother asks, "Shouldn't the baby start eating solid food? My kids started on cereal when they were 2 weeks old." Which response by the nurse would be appropriate? 1. "The baby is gaining weight and doing well. There is no need for solid food yet." 2. "Things have changed a lot since your children were born." 3. "We've found that babies can't digest solid food properly until they're 4 months old." 4. "We've learned that introducing solid food early leads to eating disorders later in life."

Correct response: "We've found that babies can't digest solid food properly until they're 4 months old." Explanation: Infants younger than 4 months lack the enzymes needed to digest complex carbohydrates. Option 1 doesn't address the grandmother's question directly. Option 2 is a cliché that may block further communication with the grandmother. Option 4 is incorrect because no evidence suggests that introducing solid food early causes eating disorders.

The nurse is approached by the mother of a child with hypospadias. She says to the nurse, "Why did this have to happen to my baby? Why couldn't he be perfect? How could this have happened?" What should the nurse say in response? 1. "This is only a minor problem. Many other babies are born with worse defects." 2. "Don't worry. After surgical repair you'll hardly remember there was anything wrong with your baby." 3. "I'll ask the physician to explain to you how this defect occurs." 4. "You seem upset. Tell me about it."

Correct response: "You seem upset. Tell me about it." Explanation: By verbalizing observations of the client's behavior, the nurse acknowledges the client's feelings. By listening, the nurse can help the client understand her feelings and begin to deal with them. Telling the client that there are babies with worse defects doesn't acknowledge — and may even belittle — her feelings. Providing a stock answer, such as "Don't worry," shows a lack of interest in the client's feelings. Offering to ask the physician also doesn't address the client's feelings.

A mother brings her 8-month-old son to the pediatrician's office. When the nurse approaches to measure the child's vital signs, he clings to his mother tightly and starts to cry. The mother says, "He used to smile at everyone. I don't know why he's acting this way." Which response by the nurse would help the mother understand her child's behavior? 1. "Your baby's behavior indicates stranger anxiety, which is common at his age." 2. "Children who behave that way are developing shy personalities." 3. "Children at his age begin to fear pain." 4. "Your baby's having a temper tantrum, which is common at his age."

Correct response: "Your baby's behavior indicates stranger anxiety, which is common at his age." Explanation: Stranger anxiety, common in infants ages 6 to 8 months, may cause the child to cry, cling to the caregiver, and turn away from strangers. Typically, it occurs when the child starts to differentiate familiar and unfamiliar people. The child's behavior doesn't necessarily indicate shyness. According to Piaget, fear of pain characterizes the operational stage of development in school-age children, not infants. Temper tantrums are typical in toddlers who are trying to assert their independence; during a temper tantrum, children may kick, scream, hold their breath, or throw themselves onto the floor.

A nurse is caring for an infant who requires intravenous therapy. The nurse notes that the only available IV pump is in a toddler's room. In which order should the nurse complete the following actions? 1. Remove pump from toddler's room. 2. Clean the pump. 3. Take pump into infant's room. 4. Use the pump. 1. 1, 2, 3, 4 2. 1, 3, 2, 4 3. 2, 1, 3, 4 4. 2, 3, 1, 4

Correct response: 1, 2, 3, 4 Explanation: Properly cleaning the monitoring equipment is the correct infection control process. Best practices would include removing the pump from the toddler's room, cleaning the pump, taking the pump into the infant's room, and using the pump.

The parents of a 6 month old diagnosed with a terminal brain tumor have chosen palliative care. Which interventions will be provided for this infant? Select all that apply. 1. pain management and comfort measures 2. curative surgery to remove the tumor 3. chemotherapy and radiation therapy for a possible cure 4. parental support enabling the parents to participate in the infant's care 5. serum blood analysis to monitor cancer levels

Correct response: 1. pain management and comfort measures 4. parental support enabling the parents to participate in the infant's care Explanation: Palliative care means comfort not cure. Pain management, comfort measures, and parental support are all part of palliative care. Surgery, chemotherapy, radiation, and blood work used to treat the cancer or cure the disease are not indicated in palliative care.

A nurse is reinforcing teaching the parents of a 6-month-old infant about normal growth and development. Which statements regarding infant development are true? Select all that apply. 1. A 6-month-old infant has difficulty holding objects. 2. A 6-month-old infant can usually roll from prone to supine and supine to prone positions. 3. A teething ring is appropriate for a 6-month-old infant. 4. Stranger anxiety usually peaks at age 12 to 18 months. 5. Head lag is commonly noted in infants at age 6 months. 6. Lack of visual coordination usually resolves by age 6 months

Correct response: 2. A 6-month-old infant can usually roll from prone to supine and supine to prone positions. 3. A teething ring is appropriate for a 6-month-old infant. 6. Lack of visual coordination usually resolves by age 6 months Explanation: Gross motor skills of the 6-month-old infant include rolling from front to back and back to front. Teething usually begins around age 6 months and, therefore, a teething ring is appropriate. Visual coordination is usually resolved by age 6 months. At age 6 months, fine motor skills include purposeful grasping and releasing of objects and transferring objects from one hand to another. Stranger anxiety normally peaks at 8 months. The 6-month-old infant also should have good head control and no longer display head lag when pulled up to a sitting position.

The nurse is educating the parents of an infant undergoing repair for a cleft lip. Which instructions should the nurse reinforce? Select all that apply. 1. Offer a pacifier as needed. 2. Lay the infant on his/her back or side to sleep. 3. Sit the infant up for each feeding. 4. Loosen the arm restraints every 4 hours. 5. Clean the suture line after each feeding by dabbing it with saline solution. 6. Give the infant extra care and support.

Correct response: 2. Lay the infant on his/her back or side to sleep. 3. Sit the infant up for each feeding. 5. Clean the suture line after each feeding by dabbing it with saline solution. 6. Give the infant extra care and support. Explanation: An infant with a repaired cleft lip should be put to sleep on the back or side to prevent trauma to the surgery site. The infant should be fed in the upright position with a syringe and attached tubing to prevent stress to the suture line from sucking. To prevent crusts and scarring, the suture line should be cleaned after each feeding by dabbing it with half-strength hydrogen peroxide or saline solution. The infant should receive extra care and support because he or she cannot meet emotional needs by sucking. Extra care and support may also prevent crying, which stresses the suture line. Pacifiers should not be used during the healing process because they stress the suture line. Arm restraints are used to keep the infant's hands away from the mouth and should be loosened every 2 hours.

A parent is planning to enroll a 9-month-old infant in a day-care facility. The parent asks a nurse what to look for as indicators that the facility is adhering to good infection control measures. The nurse identifies which as an indication of meeting proper infection control standards? Select all that apply. 1. The facility keeps boxes of gloves in the director's office. 2. Soiled diapers are discarded in covered receptacles. 3. Toys are kept on the floor for the children to share. 4. Disposable papers are used on the diaper-changing surfaces. 5. Facilities for hand hygiene are located in every classroom. 6. Soiled clothing and cloth diapers are sent home in labeled paper bags.

Correct response: 2. Soiled diapers are discarded in covered receptacles. 4. Disposable papers are used on the diaper-changing surfaces. 5. Facilities for hand hygiene are located in every classroom. Explanation: A parent can assess infection control practices by appraising steps taken by the facility to prevent the spread of disease. Placing soiled diapers in covered receptacles, covering the diaper-changing surfaces with disposable papers, and ensuring that hand sanitizers and sinks are available for personnel to wash their hands after activities are all indicators that infection control measures are being followed. Gloves should be readily available to personnel and, therefore, should be kept in every room—not in an office. Toys typically are shared by numerous children; however, this contributes to the spread of germs and infections. All soiled clothing and cloth diapers should be placed in a sealed plastic bag before being sent home.

The nurse is preparing to feed the infant. Which actions by the infant indicate readiness to feed? Select all that apply. 1. burping 2. hand to mouth 3. lies quietly awake 4. rooting 5. mouthing

Correct response: 2. hand to mouth 4. rooting 5. mouthing Explanation: Readiness to feed indicators include the infant making hand to mouth and hand to hand movements, sucking motions, rooting, and mouthing. Burping is an indicator that the infants attempt to clear gas. Lying quietly with eyes open is an alert behavior, indicating normal infant reactivity.

A child is brought to the emergency department severely dehydrated after having gastroenteritis for 4 days. The health care provider orders an IV to maintain fluid replacement for this child. (Refer to the exhibit.) If the child weighs 18 kg, what is the appropriate infusion rate in mL/h? Record the answer as a whole number.

Correct response: 58 Explanation: Since the client weighs 18 kg, this is a multistep problem. Step 1 (daily fluid requirements for the first 10 kg of bodyweight): 100 mL/kg/day × 10 kg = 1000 mL/day Step 2 (daily fluid requirements for the remaining 8 kg of bodyweight): 50 mL/kg/day × 8 kg = 400 mL/day Step 3 (convert daily fluid requirements to an hourly infusion rate): (1000 mL/day + 400 mL/day) × 1 day/24 h = 58 mL/h.

A health care provider orders an IV infusion of dextrose 5% in quarter-normal saline solution to be infused at 7 mL/kg/hour for a 10-month-old infant. The infant weighs 19 lb (8.6 kg). How many milliliters of the ordered solution should the nurse infuse each hour? Record the answer as a whole number.

Correct response: 60 Explanation: 8.6 kg × 7 mL/kg/hour = 60 mL/hour.

When discharging a 5-month-old infant from the hospital, the nurse checks to see whether the parent's car restraint system for the infant is appropriate. Which of the following restraint systems would be safest? 1. A front-facing convertible car seat in the middle of the backseat 2. A rear-facing infant safety seat in the front passenger seat 3. A rear-facing infant safety seat in the middle of the backseat 4. A front-facing convertible car seat in the backseat next to the window

Correct response: A rear-facing infant safety seat in the middle of the backseat Explanation: Infants from birth to 20 lb (9.1 kg) and younger than age 1 must be in a rear- facing infant or convertible seat in the backseat, preferably in the middle. Infants and small children should never be placed in the front seat because of the risk of injuries from a breaking front windshield and an expanding airbag. The position next to the window isn't preferred.

The charge nurse is making client care assignments. Which client is most appropriate for a licensed practical nurse? 1. A stable 6-month-old infant with pneumonia 2. A newly admitted 1-month-old infant with bronchiolitis 3. A newly admitted 15-year-old child with diabetic ketoacidosis 4. A 12-year-old child admitted for chemotherapy

Correct response: A stable 6-month-old infant with pneumonia Explanation: Of the clients listed, the most appropriate assignment for a licensed practical nurse is the stable 6-month-old infant admitted with pneumonia. A licensed practical nurse can care for clients who are stable and aren't receiving chemotherapy. Because they require close assessment, a newly admitted infant with bronchiolitis, a 15-year-old child with diabetic ketoacidosis, and a 12-year-old child who requires chemotherapy should be cared for by a registered nurse.

The nurse assesses a neonate with esophageal atresia for signs of dehydration. Which finding should the nurse expect to see? 1. Bulging of the eyeballs 2. A sunken anterior fontanel 3. Increase in the neonate's weight 4. Brisk return of the skin when pinched

Correct response: A sunken anterior fontanel Explanation: A sunken anterior fontanel is a sign of dehydration in the neonate whose fontanel has not yet closed. Bulging eyeballs and weight gain are signs of overhydration. Skin that returns quickly when pinched is a sign of adequate hydration.

The nurse is working in the emergency room and is assigned to a client with necrotizing enterocolitis. When gathering data, what finding would be expected? 1. Abdominal distention and gastric retention 2. Gastric retention and guaiac-negative stools 3. Metabolic alkalosis and abdominal distention 4. Guaiac-negative stools and metabolic alkalosis

Correct response: Abdominal distention and gastric retention Explanation: Necrotizing enterocolitis is an ischemia disorder of the gut. The cause is unknown, but it is more common in preterm neonates who have had a hypoxic episode. The neonate's intestines become dilated and necrotic, and the abdomen becomes extremely distended. Paralytic ileus develops, causing gastric retention. These retained gastric contents, along with any passed stool, will be guaiac positive. The neonate also develops metabolic acidosis, not metabolic alkalosis.

The nurse is caring for an infant diagnosed with thrush. Which instruction should the nurse give to a client's mother who will be administering nystatin oral solution? 1. Administer the drug right after meals by swabbing the mouth. 2. Administer the drug right before meals by using a gauze pad. 3. Mix the drug with small amounts of formula in bottle. 4. Administer half the dose before and half after a feeding.

Correct response: Administer the drug right after meals by swabbing the mouth. Explanation: Nystatin oral solution is an antifungal medication used to treat fungal or yeast infections. Nystatin oral solution should be swished around the mouth after eating for the best contact with mucous membranes. Taking the drug before or with meals does not allow for optimal contact with mucous membranes.

An infant admitted with reactive airway disease is dyspneic and cyanotic. Which intervention takes priority when caring for this infant? 1. Administering antibiotics immediately, as prescribed 2. Keeping the room quiet and dim 3. Explaining all procedures to the parents 4. Administering albuterol by nebulizer, as prescribed

Correct response: Administering albuterol by nebulizer, as prescribed Explanation: Because the infant is dyspneic and cyanotic, the first priority is to administer the albuterol so the infant's bronchioles will dilate and the respiratory distress will be alleviated. It's important to explain all procedures to the parents, but that can be done as the nurse is administering the nebulizer treatment. Keeping the room quiet is a good idea, but keeping it dim could interfere with the need to assess the infant's color. Antibiotics should be administered as soon as possible but after the nebulizer treatment.

When planning to administer medication to a 3-month-old infant, the nurse should keep which consideration in mind? 1. An infant's metabolic rate is slower than an adult's. 2. An infant's liver detoxifies drugs faster than an adult's. 3. An infant has slower systemic drug circulation than an adult does. 4. An infant's kidneys excrete drugs more slowly than an adult's.

Correct response: An infant's kidneys excrete drugs more slowly than an adult's. Explanation: Most drugs are excreted by the kidneys. Because an infant has immature kidney function, drugs are excreted more slowly, significantly altering drug effects. An infant has a faster metabolic rate, slower drug detoxification, and faster systemic drug circulation than an adult.

A 2-month-old with a history of hydrocephalus is admitted to the pediatric unit with pneumonia. The infant's respiratory status deteriorates and the physician explains to the family that the infant requires intensive care. The grandmother convinces the parents to refuse transfer and institute comfort measures. Which action should the nurse take? 1. Follow the parents' wishes because she agrees with their decision. 2. Ask to speak to the parents privately without the grandmother present. 3. Facilitate the infant's transfer according to the physician's order. 4. Remind the grandmother that treatment decisions must be left to the parents.

Correct response: Ask to speak to the parents privately without the grandmother present. Explanation: The nurse should ask to speak to the parents privately without the grandmother present to make sure that they're making a decision that they feel comfortable with. The grandmother has the right to voice her opinion but the decision must come from the parents. The nurse shouldn't voice her opinion about the infant's treatment plan. The nurse shouldn't facilitate the transfer to the intensive care unit without the parents' decision to do so. Reminding the grandmother that treatment decisions must be left to the parents is disrespectful and unprofessional.

Before a routine checkup in the pediatrician's office, an 8-month-old infant sits contentedly on the mother's lap, chewing on a toy. When preparing to examine this infant, what should the nurse plan to do first? 1. Measure the head circumference. 2. Auscultate the heart and lungs. 3. Elicit the pupillary reaction. 4. Weigh the child.

Correct response: Auscultate the heart and lungs. Explanation: Heart and lung auscultation rarely distresses an infant, so it should be done early in data collection. Placing a tape measure on the infant's head, shining a light in the eyes, or undressing the infant before weighing may cause distress, making the rest of the examination more difficult.

The nurse would explain to the parents of a newborn with a cleft lip and palate that they will need to schedule an appointment with which specialist? 1. Cardiologist 2. Neurologist 3. Nutritionist 4. Otolaryngologist

Correct response: Otolaryngologist Explanation: An appointment with an otolaryngologist is important because ear infections are common in the neonate with a cleft lip and palate, along with hearing loss. Brain and cardiac function are usually normal. A nutritionist is not needed unless the neonate becomes malnourished.

The parent of a 6-month-old infant with atopic dermatitis asks for advice on bathing the child. Which instructions or information should the nurse give to the parent? 1. Bathe the infant twice daily. 2. Bathe the infant every other day. 3. Use bubble baths to decrease itching. 4. The frequency of the infant's baths isn't important in atopic dermatitis.

Correct response: Bathe the infant every other day. Explanation: Bathing removes lipoprotein complexes that hold water in the stratum corneum and increases water loss. Decreasing bathing to every other day can help prevent the removal of lipoprotein complexes. Soap and bubble bath should be used sparingly while bathing the child.

The parent of a 6-month-old infant with atopic dermatitis asks for advice on bathing the child. Which instructions or information should the nurse give to the parent? Bathe the infant twice daily. Bathe the infant every other day. Use bubble baths to decrease itching. The frequency of the infant's baths isn't important in atopic dermatitis.

Correct response: Bathe the infant every other day. Explanation: Bathing removes lipoprotein complexes that hold water in the stratum corneum and increases water loss. Decreasing bathing to every other day can help prevent the removal of lipoprotein complexes. Soap and bubble bath should be used sparingly while bathing the child.

Which intervention by the nurse would be most helpful when discussing hypospadias with the parents of an infant with this defect? 1. Refer the parents to a counselor. 2. Be there to listen to the parents' concerns. 3. Notify the health care provider, and have him talk to the parents. 4. Suggest a support group of other parents who have gone through this experience.

Correct response: Be there to listen to the parents' concerns. Explanation: The nurse must recognize that parents are going to grieve the loss of the normal child when they have a neonate born with a birth defect. Initially, the parents need to have a nurse who will listen to their concerns for their neonate's health. Suggesting a support group or referring the parents to a counselor might be helpful, but not initially. The health care provider will need to spend time with the parents to discuss surgery, but the nurse is in the best position to allow the parents to vent their grief and anger initially.

When preparing to feed an infant with pyloric stenosis, which intervention should the nurse give highest priority? 1. Give feedings quickly. 2. Burp the infant frequently. 3. Discourage parental participation. 4. Discontinue feedings if the infant vomits.

Correct response: Burp the infant frequently. Explanation: Infants with pyloric stenosis usually swallow a lot of air from sucking on their hands and fingers because of their intense hunger (feedings aren't easily tolerated). Burping often lessens gastric distention and increases the likelihood the infant will retain the feeding. Feedings are given slowly with the infant lying in a semi-upright position. Parental participation should be encouraged and allowed to the extent possible. Record the type, amount, and character of the vomit as well as its relation to the feeding. The amount of feeding volume lost is usually refed.

Which nursing intervention has the highest priority in the care of an infant during the first 24 hours after surgery for cleft lip? 1. Carefully clean the suture line after feedings using sterile technique. 2. Position the infant in the prone position after feedings. 3. Allow the infant to cry to promote lung expansion. 4. Provide the infant with a pacifier to satisfy the urge to suck.

Correct response: Carefully clean the suture line after feedings using sterile technique. Explanation: The suture line must be cleaned after each feeding to reduce the risk of infection, which could adversely affect the healing and cosmetic results. The incision should be cleaned carefully so the sutures are not disrupted. A sterile solution should be used to reduce the risk of infection. The infant should not be placed on his abdomen in the prone position because this puts pressure on the incision and may affect healing. Anticipatory care should be provided to reduce the risk of the infant crying, which puts pressure on the incision. Pacifiers and other firm objects should not be placed in the infant's mouth because they can disrupt the suture line.

A nurse observes a hospitalized 10-month-old infant chewing on the security alarm attached to his identification bracelet. What intervention is most appropriate for the nurse to perform? 1. Remove the security device because it's a choking hazard. 2. Cover the device with gauze wrap so that it isn't visible. 3. Distract the infant with a more appropriate toy. 4. Instruct the infant's parents regarding the safety hazard.

Correct response: Distract the infant with a more appropriate toy. Explanation: Distraction with an appropriate toy provides safety and is developmentally supportive. Removing the security device isn't appropriate; the device must remain attached to the infant for security reasons. Covering the device does not satisfy the infant's need to chew. Instructing the infant's parents about the safety hazard isn't the best response. Doing so won't eliminate the immediate hazard and doesn't refocus the infant's attention.

At a previous visit, the parents of an infant with cystic fibrosis received instruction in the administration of pancrelipase. At a follow-up visit, which finding suggests the need for further teaching? 1. Fatty stools 2. Bloody urine 3. Bloody stools 4. Glucose in urine

Correct response: Fatty stools Explanation: Pancreatic enzymes normally aid in food digestion in the intestine. In a child with cystic fibrosis, however, these natural enzymes can't reach the intestine because mucus blocks the pancreatic duct. Without these enzymes, undigested fats and proteins produce fatty stools. Treatment with pancreatic enzymes should result in stools of normal consistency; noncompliance with the treatment produces fatty stools. Noncompliance doesn't cause bloody urine, bloody stools, or glucose in urine

A 2-month-old infant arrives in the emergency department with a heart rate of 180 beats/minute and a temperature of 103.1° F (39.5° C) rectally. Which intervention is most appropriate? 1. Give acetaminophen. 2. Encourage fluid intake. 3. Apply carotid massage. 4. Place the infant's hands in cold water.

Correct response: Give acetaminophen. Explanation: Acetaminophen should be given first to decrease the infant's temperature. A heart rate of 180 beats/minute is normal in an infant with a fever. Fluid intake is encouraged after the acetaminophen is given to help replace insensible fluid losses. Carotid massage is an attempt to decrease the heart rate as a vagal maneuver; it won't work in this infant because the source of the increased heart rate is fever. A tepid sponge bath may be given to help decrease the temperature and calm the infant.

The nurse is caring for an infant diagnosed with pyloric stenosis. Which intervention should the nurse perform to help prevent vomiting? 1. Hold the infant for 1 hour after feeding. 2. Handle the infant minimally after feedings. 3. Space out feedings and give large amounts. 4. Lay the infant prone with the head of the bed elevated.

Correct response: Handle the infant minimally after feedings. Explanation: Minimal handling, especially after a feeding will help prevent vomiting. Holding the infant would provide too much stimulation, increasing the risk of vomiting. Feedings are given frequently and slowly in small amounts. An infant should be positioned in semi-Fowler's position and slightly on the right side after a feeding.

How should a nurse position an infant when administering an oral medication? 1. Seated in a high chair 2. Restrained flat in the crib 3. Held on the nurse's lap 4. Held in the bottle- or breast-feeding position

Correct response: Held in the bottle- or breast-feeding position Explanation: A nurse should hold an infant in the bottle- or breast-feeding position when administering an oral medication by placing the child's inner arm behind his back, supporting his head in the crook of the elbow, and holding the child's free hand with the hand of the supporting arm. An infant shouldn't sit unsupported in a high chair. Administering medication to an infant lying flat could cause choking and aspiration. Holding the infant in the lap doesn't prevent the infant's arms from moving around, which may cause the medicine to spill.

After surgery to repair a cleft lip, an infant has a Logan bar in place. Which postoperative nursing action is appropriate? 1. Removing the Logan bar during feedings 2. Holding the infant semi-upright during feedings 3. Burping the infant less frequently 4. Placing the infant on the abdomen after feedings

Correct response: Holding the infant semi-upright during feedings Explanation: Holding the infant semi-upright during feedings helps prevent aspiration. The Logan bar must be kept in place at all times to protect the suture line. The infant should be burped more frequently to prevent regurgitation and aspiration. Placing the infant on his abdomen could lead to disruption of the suture line if the infant rubs his face.

The nurse is administering medication to a 6-week-old infant. Which factor is the nurse most correct to identify as likely to decrease the infant's ability for drug metabolism? 1. Decreased glomerular filtration 2. Reduced protein-binding ability 3. Increased tubular secretion 4. Inefficient liver function

Correct response: Inefficient liver function Explanation: When administering medications to pediatric clients, the nurse must understand pharmacokinetics. Inefficient liver function potentially decreases drug metabolism in the infant. As the liver matures during the first year of life, drug metabolism improves. Decreased glomerular filtration and increased tubular secretion may affect drug excretion rather than metabolism. Reduced protein-binding ability may affect drug distribution but not metabolism.

A mother is discontinuing breast-feeding after 3 months. The nurse should advise her to include which item in her infant's diet? 1. Iron-fortified formula and baby food 2. Whole milk and baby food 3. Skim milk and baby food 4. Iron-fortified formula alone

Correct response: Iron-fortified formula alone Explanation: The American Academy of Pediatrics (Canadian Pediatric Society) recommends breast-feeding infants for at least 12 months. When breast-feeding isn't possible, an iron-fortified formula is recommended. By age 6 months, an infant should be mature enough to begin eating iron-fortified cereal mixed with formula or breast milk. The Academy doesn't recommend whole milk before age 12 months or skim milk before age 2 years.

A 1-year-old infant with bronchopulmonary dysplasia has just received a tracheostomy. Which intervention by the nurse is appropriate? 1. Keep extra tracheostomy tubes at the bedside. 2. Secure ties at the side of the neck. 3. Change the tracheostomy tube 2 weeks after surgery. 4. Secure the tracheostomy ties tightly to prevent dislodgment of the tube.

Correct response: Keep extra tracheostomy tubes at the bedside. Explanation: Extra tracheostomy tubes should be kept at the bedside in case of an emergency, including one size smaller in case the appropriate size doesn't fit due to edema. The ties should be placed securely but should allow some space (the width of a pinky finger) to prevent excessive pressure or skin breakdown. The first tracheostomy tube change is usually performed by the health care provider after 7 days. Ties are placed at the back of the neck.

A nurse is caring for an infant with meningitis. Which nursing action is a priority? 1. Maintain an adequate airway. 2. Maintain fluid and electrolyte balance. 3. Control seizures. 4. Control hyperthermia.

Correct response: Maintain an adequate airway. Explanation: Maintaining an adequate airway is always a top priority. Maintaining fluid and electrolyte balance and controlling seizures and hyperthermia are all important, but maintaining an adequate airway takes priority.

An infant is hospitalized for treatment of nonorganic failure to thrive. Which nursing action is most appropriate for this child? 1. Encouraging the infant to hold a bottle 2. Keeping the infant on bed rest to conserve energy 3. Rotating caregivers to provide more stimulation 4. Maintaining a consistent, structured environment

Correct response: Maintaining a consistent, structured environment Explanation: The nurse caring for an infant with nonorganic failure to thrive should strive to maintain a consistent, structured 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.

A neonate born 18 hours ago with myelomeningocele over the lumbosacral region is scheduled for corrective surgery. Preoperatively, what is the most important nursing goal? 1. Preventing infection 2. Ensuring adequate hydration 3. Providing adequate nutrition 4. Preventing contracture deformity

Correct response: Preventing infection Explanation: Preventing infection is the nurse's primary preoperative goal for a neonate with myelomeningocele. Although the other options are relevant for this neonate, they're secondary to preventing infection.

An infant requires cardiorespiratory monitoring. A nurse must locate and clean the necessary equipment, move it into the infant's room, and secure it to the bedside wall-mounting device. Which principles should a nurse use to complete this task safely? 1. Principles of geometry and mathematics 2. Principles of ergonomics and geometry 3. Principles of sterile technique and mathematics 4. Principles of infection control and ergonomics

Correct response: Principles of infection control and ergonomics Explanation: Properly cleaning the monitoring equipment involves infection control. Properly placing and securing the monitor uses ergonomic principles. The principles of geometry and mathematics aren't relevant to safety.

To obtain the most accurate measurement of an infant's height (length), the nurse should measure which of the following? 1. Recumbent height with the infant lying on the side 2. Recumbent height with the infant supine 3. Recumbent height with the infant prone 4. Standing height with the infant held upright

Correct response: Recumbent height with the infant supine Explanation: For the most accurate measurement, the nurse should place the infant in a supine position and then measure recumbent height. Measuring recumbent height with the infant lying on the side would yield an inaccurate result because the infant's body can't be extended adequately. Measuring recumbent height with the infant prone would yield an inaccurately long result because it includes the length of the foot. Measuring standing height with the infant held upright would yield an inaccurate result until the child no longer needs assistance to stand up straight.

The nurse is caring for an infant who has undergone a surgical repair of a cleft lip. The health care provider prescribes elbow restraints. What nursing action should be included in the infant's plan of care? 1. Remove the restraints every 2 hours. 2. Remove the restraints while the infant is asleep. 3. Keep the restraints on one arm at a time. 4. Use the restraints until the infant fully recovers from anesthesia.

Correct response: Remove the restraints every 2 hours. Explanation: The nurse should remove one elbow restraint at a time every 2 hours for about 5 minutes to allow exercise of the arms and to inspect the infant for skin irritation. To prevent the infant from touching and disrupting the suture line, the nurse should use the restraints when the infant is asleep and awake. Both arms should be restrained to be effective. The nurse should maintain the elbow restraints from the time the infant recovers from anesthesia until the suture line is healed.

A nurse suspects an infant may have a tracheoesophageal fistula or esophageal atresia. What is the most important intervention by the nurse? 1. Give oxygen. 2. Tell the parents. 3. Put the neonate in an isolette or on a radiant warmer. 4. Report the suspicion to the health care provider.

Correct response: Report the suspicion to the health care provider. Explanation: The provider needs to be told so that immediate diagnostic tests can be done to determine a definitive diagnosis with surgical correction. Oxygen should be given only after notifying the provider, except in an emergency. It is not the nurse's responsibility to inform the parents of the suspected finding. By the time tracheoesophageal fistula or esophageal atresia is suspected, the neonate would have already been placed in an isolette or a radiant warmer.

When talking to the parents of a neonate with congenital hypothyroidism, the nurse should encourage which action? 1. Seek professional genetic counseling. 2. Retrace the family tree for others born with this condition. 3. Talk to relatives who have gone through a similar experience. 4. Wait until the neonate is 1 year of age before obtaining counseling.

Correct response: Seek professional genetic counseling. Explanation: Seeking professional genetic counseling is the best option for parents who have a neonate with a genetic disorder, such as congenital hypothyroidism. Retracing the family tree and talking to relatives will not help the parents become better educated about the disorder. Education about the disorder should occur as soon as the parents are ready, so they will understand the genetic implications for future children.

The nurse is collecting data on an 8-month-old infant during a wellness checkup. Which of the following is a normal developmental task for an infant this age? 1. Sitting without support 2. Saying two words 3. Feeding himself with a spoon 4. Playing patty-cake

Correct response: Sitting without support Explanation: According to the Denver Developmental Screening Test, most infants should be able to sit unsupported by age 7 months. A 15-month-old child should be able to say two words. By 17 months, the toddler should be able to feed himself with a spoon. A 10-month-old infant should be able to play patty-cake

When collecting data on an infant diagnosed with pyloric stenosis, which finding should the nurse anticipate? 1. decreased bowel sounds 2. irregular heart murmur 3. normal respiratory effort 4. increased bowel sounds

Correct response: decreased bowel sounds Explanation: Bowel sounds decrease in an infant with pyloric stenosis because food cannot pass into the intestines. Normal respiratory effort is adversely affected due to the abdominal distention that pushes the diaphragm up into the pleural cavity. Heart murmurs may be present, but are not directly associated with pyloric stenosis.

The nurse is obtaining data from a 1-month-old infant during a routine examination at a family health center. Which method does the nurse use to test for Babinski sign? 1. Raise the child's leg with the knee flexed and then extend the child's leg at the knee to determine if resistance is noted. 2. With the knee flexed, dorsiflex the foot to determine if there's pain in the calf of the leg. 3. Flex the child's head while he's in a supine position to determine if the knees or hips flex involuntarily. 4. Stroke the bottom of the foot to determine if there's fanning and dorsiflexion of the big toe.

Correct response: Stroke the bottom of the foot to determine if there's fanning and dorsiflexion of the big toe. Explanation: To test for Babinski sign, stroke the bottom of the foot to determine if there's fanning and dorsiflexion of the big toe. Raising the child's leg with the knee flexed and then extending the leg at the knee to determine resistance are noted tests for Kernig's sign. Dorsiflexion of the foot with the knee flexed to determine if there's pain in the calf of the leg tests for Homans sign. Flexing the child's head while he's in a supine position to determine if the knees or hips flex involuntarily tests for Brudzinski's sign.

An 11-month-old infant with bronchopulmonary dysplasia and a tracheostomy experiences a decline in oxygen saturation from 97% to 88%. The infant appears anxious and the heart rate is 180 beats/minute. Which intervention is most appropriate? 1. Change the tracheostomy tube. 2. Suction the tracheostomy tube. 3. Obtain an arterial blood gas (ABG) level. 4. Increase the oxygen flow rate.

Correct response: Suction the tracheostomy tube. Explanation: Tracheostomy tubes, particularly in small children, require frequent suctioning to remove mucus plugs and excessive secretions. The tracheostomy tube can be changed if suctioning is unsuccessful. Obtaining an ABG level may be beneficial if oxygen saturation remains low and the child appears to be in respiratory distress. Increasing the oxygen flow rate will only help if the airway is patent

A 9-month-old infant is scheduled for an inguinal hernia repair. The divorced parents share joint custody of the infant. What determines who can give informed consent for the procedure? 1. The divorce decree should specify which parent has the right to sign the informed consent form. 2. A court-appointed guardian must provide informed consent. 3. The judge who granted the original custody order must grant consent. 4. The state in which the infant resides must grant permission for the surgery.

Correct response: The divorce decree should specify which parent has the right to sign the informed consent form. Explanation: The divorce decree should explain who has the right to sign the informed consent form for the infant. The parents share custody of the infant so a legal guardian wouldn't be appointed. The judge who granted custody has no jurisdiction to provide consent. The state wouldn't become involved with the infant unless, for some reason, he became a ward of the state.

The nurse is gathering data for an infant experiencing a sickle cell crisis. Which finding by the nurse is most significant to determine the state of hydration? 1. The infant has no bruises. 2. The infant has normal skin turgor. 3. The infant participates in exercise. 4. The infant maintains bladder control.

Correct response: The infant has normal skin turgor. Explanation: Normal skin turgor indicates the infant isn't severely dehydrated. Dehydration may cause sickle cell crisis or worsen a crisis. Bruising isn't associated with sickle cell crisis. Bed rest is preferable during a sickle cell crisis. Bladder control may be lost when oral or IV fluid intake is increased during a sickle cell crisis.

A 6-month-old is brought to the emergency department with a suspected femur fracture. The parents state that the infant fell from the couch. The X-ray reveals a spiral fracture of the femur. What is the priority action for the nurse to take? 1. Immediately ask the parents to leave the room and refuse to give them any information about the infant. 2. Inform the parents that the nurse suspects child abuse and must notify social services. 3. Treat the parents professionally and answer their questions appropriately. 4. Call security immediately, and inform them of the abuse.

Correct response: Treat the parents professionally and answer their questions appropriately. Explanation: Although the nurse may suspect abuse, the nurse must treat the parents professionally and answer their questions appropriately. The nurse should not ask the parents to leave the infant's room or tell them that that abuse is suspected. Until social services investigates the case, parental rights remain intact. The nurse has no reason to call security at this time.

A neonate is recovering from surgery to repair a cleft lip. What should the nurse do to prevent trauma to the suture line? 1. Use a straw for feedings. 2. Use a bulb syringe with a rubber tip for feedings. 3. Administer foods at the front of the mouth. 4. Place the infant in a prone position after feeding.

Correct response: Use a bulb syringe with a rubber tip for feedings. Explanation: A bulb syringe with a rubber tip is a safe, effective feeding device for a neonate who has undergone surgery to repair a cleft lip. Foods should be administered at the side of the mouth, not at the front, to prevent trauma to the suture line. A straw should never be used for feedings. The infant should be placed on his right side after feeding to prevent aspiration. The infant shouldn't be placed prone because this position places pressure on the suture line.

An infant is diagnosed with bronchopulmonary dysplasia. What is a priority problem that the nurse expects to see in the plan of care? 1. failure to thrive 2. effective breast-feeding 3. decreased oxygen saturation 4. fluid volume overload

Correct response: decreased oxygen saturation Explanation: The infant will have impaired gas exchange related to retention of carbon dioxide and borderline oxygenation secondary to fibrosis of the lungs, leading to decreased oxygen saturations. Although the infant may require increased caloric intake and may have excess fluid volume, oxygen saturation is the higher priority.

For an infant who's about to undergo a lumbar puncture, the nurse should place the infant in: 1. an arched, side-lying position, with the neck flexed onto the chest. 2. an arched, side-lying position, avoiding flexion of the neck onto the chest. 3. a mummy restraint. 4. a prone position, with the head over the edge of the bed.

Correct response: an arched, side-lying position, avoiding flexion of the neck onto the chest. Explanation: For a lumbar puncture, the nurse should place the infant in an arched, side- lying position to maximize the space between the third and fifth lumbar vertebrae. The nurse's hands should rest on the back of the infant's shoulders to prevent neck flexion, which could block the airway and cause respiratory arrest. The infant should be placed at the edge of the bed or table during the procedure, and the nurse should speak quietly to calm the child. A mummy restraint would limit access to the lumbar area because it involves wrapping the child's trunk and extremities snugly in a blanket or towel. A prone position wouldn't cause separation of the vertebral spaces.

Which problem would the nurse expect to find on the care plan of a 10-month-old infant to promote coping during hospitalization? 1. self-care deficit 2. powerlessness 3. boredom 4. anxiety

Correct response: anxiety Explanation: Attachment is critical in infancy, and prolonged separation has been well documented as a risk factor that compromises normal infant development. Being separated from parents can cause high anxiety. Self-care deficit wouldn't be an issue for a 10 month old. Powerlessness is a concern after the toddler stage, when a child develops autonomy and independence. Boredom won't be an issue until the acute phase of the illness has passed. Providing diversion for infants is easily accomplished by the use of age-appropriate toys and play activities.

Which plan is most appropriate for a discharge home visit to parents who lost an infant to sudden infant death syndrome (SIDS)? 1. one visit in 2 weeks 2. No visit is necessary. 3. as soon after death as possible 4. one visit with parents only, no siblings

Correct response: as soon after death as possible Explanation: When parents return home, a visit is necessary as soon after the death as possible. The nurse should assess what the parents have been told, what they think happened, and how they've explained this to the other siblings. Not all of these issues will be resolved in one visit. The number of visits and plan for intervention must be flexible. The needs of the siblings must always be considered.

A mother brings her 2-month-old infant to the clinic for a well-baby checkup. To best assess the interaction between the mother and infant, the nurse should observe them: 1. as the infant plays. 2. as the infant sleeps. 3. as the mother feeds the infant. 4. as the mother rocks the infant.

Correct response: as the mother feeds the infant. Explanation: The nurse can best assess mother-infant interaction during feeding, such as by observing how closely the mother holds the infant and how she looks at the infant's face. These behaviors help reveal the mother's anxiety level and overall feelings for the infant. The infant's posture and response during feeding provide clues to the infant's comfort level and feelings. Sleeping doesn't provide an opportunity for mother-infant interaction. Although playing and rocking may provide clues about mother-infant interaction, they aren't the best activities to assess. During playing, for instance, the mother may interact with the infant at a distance. Rocking promotes closeness but not interaction; the mother can rock the infant while talking to someone else or staring off into the distance.

An infant is diagnosed with a congenital hip dislocation. The nurse should expect to note: 1. symmetrical thigh and gluteal folds. 2. asymmetrical thigh and gluteal folds. 3. increased hip abduction. 4. femoral lengthening.

Correct response: asymmetrical thigh and gluteal folds. Explanation: Asymmetrical thigh and gluteal folds, limited hip abduction, unequal leg length, and a positive Ortolani's sign (a click or popping sensation that's felt or heard when a neonate's hip is flexed 90 degrees and abducted) are present with congenital hip dislocation.

Which activity should be recommended for long-term support of parents who have lost an infant due to sudden infant death syndrome (SIDS)? 1. attending support groups 2. attending church regularly 3. attending counseling sessions 4. discussing feelings with family and friends

Correct response: attending support groups Explanation: The best support will come from parents who have had the same experience. Attending church and discussing feelings with family and friends can offer support, but they may not understand the experience. Counseling sessions are usually a short-term support.

A nurse performs cardiopulmonary resuscitation (CPR) for 1 minute on an infant without calling for assistance. In reassessing the infant after 1 minute of CPR, the nurse finds the infant still isn't breathing and has no pulse. The nurse should then: 1. resume CPR beginning with breaths. 2. declare her efforts futile. 3. resume CPR beginning with chest compressions. 4. call for assistance.

Correct response: call for assistance. Explanation: After 1 minute of CPR, the nurse should call for assistance and then resume efforts. CPR shouldn't be stopped after it has been started unless the nurse is too exhausted to continue. A cycle usually ends with breaths, so the next beginning cycle after pulse check and summoning help would begin with chest compressions.

A 3-month-old infant is admitted to the hospital to rule out nonaccidental trauma. X-ray findings indicate a fractured right humerus, fractured ribs, and a fractured left scapula. In this situation, a nurse is responsible for: 1. ensuring that the suspected child abuse is reported to local authorities. 2. contacting the infant's next of kin to begin discharge planning. 3. reporting the suspicions to the hospital's chief of pediatric services. 4. contacting the local children's protective service office with an anonymous tip.

Correct response: ensuring that the suspected child abuse is reported to local authorities. Explanation: Nurses must report suspicions of child abuse to local authorities. The contact procedure may vary among hospitals, but the nurse is responsible for making the report. Reporting suspected abuse to the hospital's chief of pediatric services isn't appropriate. Contacting the infant's next of kin to begin discharge planning is inappropriate because the infant may not be discharged to the next of kin. Providing an anonymous tip isn't appropriate behavior for a professional nurse. The hospital record is important to the legal process, and the nurse must handle it professionally.

The nurse cares for an infant receiving inadequate treatment for congenital hypothyroidism. Which signs or symptoms should the nurse expect to observe? 1. irritability and jitteriness 2. fatigue and sleepiness 3. increased appetite 4. diarrhea

Correct response: fatigue and sleepiness Explanation: Signs of inadequate treatment in an infant with congenital hypothyroidism are fatigue, sleepiness, decreased appetite, and constipation.

The nurse is caring for an infant with hypospadias. Which anomaly would the nurse assess the infant for that commonly accompanies this condition? 1. indescended testes 2. ambiguous genitalia 3. umbilical hernias 4. inguinal hernias

Correct response: indescended testes Explanation: Because undescended testes may also be present in hypospadias, the small penis may appear to be an enlarged clitoris. This shouldn't be mistaken for ambiguous genitalia. If there's any doubt, more tests should be performed. Hernias don't generally accompany hypospadias.

A mother and infant are admitted to the emergency department following a motor vehicle collision. The mother has a Glasgow coma scale score of 6. The parents are divorced and have joint custody of the infant. The infant's father was not involved in the collision and arrives in the emergency department. Who should the nurse contact about consent for treatment of the infant? 1. Child Protective Services representative 2. infant's mother 3. infant's father 4. mother's listed next of kin

Correct response: infant's father Explanation: The father may give consent for treatment of the infant because he has legal custody. Even if verbal, the mother should not be asked for consent, because the current Glasgow coma scale result meets the criteria for severe brain injury (score less than 8 out of a possible 15). The mother's next of kin should be contacted for consent for her treatment (if needed) but not for the infant's treatment as the father is the infant's next of kin. Because the father may give consent for the infant to be treated, it isn't necessary to contact Child Protective Services.

Which complications should the nurse be most concerned about in the first 12 hours of life for a neonate born with a myelomeningocele? 1. infection 2. constipation 3. impaired physical mobility 4. delayed growth and development

Correct response: infection Explanation: All of these complications are a potential for a child with a myelomeningocele. However, during the first 12 hours of life, the most life-threatening event would be an infection. The other potential complications will be addressed as the child develops.

A 3-month-old infant with meningococcal meningitis has just been admitted to the pediatric unit. Which nursing intervention has the highest priority? 1. instituting droplet precautions 2. administering acetaminophen 3. obtaining history information from the parents 4. orienting the parents to the pediatric unit

Correct response: instituting droplet precautions Explanation: Instituting droplet precautions is the priority for a newly admitted infant with meningococcal meningitis. Acetaminophen may be prescribed, but administering it does not take priority over instituting droplet precautions. Obtaining history information and orienting the parents to the unit do not take priority.

An infant, age 10 months, is brought to the well-baby clinic for a follow-up visit. The mother tells the nurse that she has been having trouble feeding her infant solid foods. To help correct this problem, the nurse should: 1. point out that tongue thrusting is the infant's way of rejecting food. 2. instruct the mother to place the food at the back and toward the side of the infant's mouth. 3. advise the mother to puree foods if the child resists them in solid form. 4. suggest that the mother force-feed the child if necessary.

Correct response: instruct the mother to place the food at the back and toward the side of the infant's mouth. Explanation: Placing the food at the back and toward the side of the infant's mouth encourages swallowing. Tongue thrusting is a physiologic response to food placed incorrectly in the mouth. Offering pureed foods wouldn't encourage swallowing, which is a learned behavior. Force-feeding may be frustrating for both the mother and child and may cause the child to gag and choke when attempting to reject the undesired food; also, it may lead to a higher-than-normal caloric intake, resulting in obesity.

When collecting data on an infant, which condition would alert the nurse as a subtle sign of hypothyroidism? 1. diarrhea 2. lethargy 3. severe jaundice 4. tachycardia

Correct response: lethargy Explanation: Subtle signs of hypothyroidism that may be seen shortly after birth include lethargy, poor feeding, prolonged jaundice, respiratory difficulty, cyanosis, constipation, and bradycardia. Diarrhea in the neonate isn't normal and isn't associated with this disorder. Severe jaundice needs immediate attention by the primary health care provider and isn't a subtle sign. Tachycardia typically occurs in hyperthyroidism, not hypothyroidism.

A nurse is observing an infant with thyroid hormone deficiency. Which signs would the nurse commonly observe? 1. tachycardia, profuse perspiration, and diarrhea 2. lethargy, feeding difficulties, and constipation 3. hypertonia, small fontanels, and moist skin 4. dermatitis, dry skin, and round face

Correct response: lethargy, feeding difficulties, and constipation Explanation: Hypothyroidism results from inadequate thyroid production to meet an infant's needs. Clinical signs include feeding difficulties, prolonged physiologic jaundice, lethargy, and constipation

A nurse is caring for an infant with congenital clubfoot. After the final cast has been removed, which member of the health care team will most likely help the infant with leg and ankle exercises and provide the parents with a home exercise regimen? 1. occupational therapist 2. physical therapist 3. recreational therapist 4. speech therapist

Correct response: physical therapist Explanation: After the final cast has been removed from the infant born with congenital clubfoot, foot and ankle exercises may be necessary to improve the infant's range of motion. A physical therapist is trained to help clients restore function and mobility, which prevents further disability. An occupational therapist, who helps chronically ill and disabled clients perform activities of daily living and adapt to limitations, is not necessary at this time. A recreational therapist, who uses games and group activities to redirect maladaptive energy into appropriate behavior, also is not required. A speech therapist is not necessary because clubfoot is not associated with speech problems.

An infant is examined and found to have a petechial rash. How will the nurse document this finding? 1. purple macular lesions larger than 1 cm in diameter 2. purple to brown bruises, macular or papular, of various sizes 3. a collection of blood from ruptured blood vessels and larger than 1 cm in diameter 4. pinpoint, pink to purple, nonblanching, macular lesions that are 1 to 3 mm in diameter

Correct response: pinpoint, pink to purple, nonblanching, macular lesions that are 1 to 3 mm in diameter Explanation: Petechiae are small pinpoint, pink to purple, macular lesions 1 to 3 mm in diameter. Purple, macular lesions greater than 1 cm in diameter are defined as purpura. A bruise is defined as ecchymosis. A hematoma is a collection of blood.

The nurse is caring for an infant following the surgical repair of a cleft lip. The infant's pain is being managed effectively. What does the nurse determine is the priority goal for this client? 1. improve nutrition 2. prevent infection 3. prevent dehydration 4. teaching the mother to feed the baby

Correct response: prevent infection Explanation: After surgery, a priority nursing goal is to prevent infection. Surgery involves an incision on skin and mucus membranes, which places the infant at risk for infection. It is important that the infant not touch the incision line or disrupt the sutures. The infant's arms are placed in restraints to keep them from touching the suture line or attempting to suck on their fingers. Teaching the parents to feed with special feeders or with a spoon is a necessary part of recovery care. Nutrition should be maintained throughout the recovery process and will improve as the infant is better able to grasp the nipple to suck. The mother will be taught how to feed the baby with special feeding devices. Many parents are already using these devices at home to feed the child.

The nurse caring for an infant with pyloric stenosis should be alert for which classic sign or symptom? 1. loss of appetite 2. chronic diarrhea 3. projectile vomiting 4. excessive drooling

Correct response: projectile vomiting Explanation: The obstruction seen in pyloric stenosis doesn't allow food to pass through to the duodenum. The classic sign of projectile vomiting occurs when the stomach becomes full, and the infant vomits for relief. Drooling would not be a finding in a child with pyloric stenosis but rather in a child with tracheoesophageal fistula. Chronic hunger is commonly seen. There's no diarrhea because food doesn't pass the stomach.

The parent of a neonate born with a cleft lip and palate prepares to feed the child for the first time. Which parent education should the nurse reinforce as a priority of care before the parent attempts the first feeding? 1. methods of burping the neonate 2. how to clean the neonate's mouth 3. proper positioning of the neonate 4. how to lay the neonate down

Correct response: proper positioning of the neonate Explanation: When neonates are held in the upright position, the formula is less likely to leak out the nose or mouth. Neonates need to be burped frequently after feeding. There is no need to clean the mouth before eating and the infant should be positioned after feeding to prevent aspiration. After surgical repair, the mouth is cleaned at the suture site to prevent infection. The bottle should be prepared using a special nipple or feeding device.

Which precaution should a nurse caring for a 2-month-old infant with respiratory syncytial virus (RSV) take to prevent the spread of infection? 1. wear gloves only 2. wear gown, gloves, and mask 3. no precautions are required; the virus isn't contagious 4. proper hand washing between clients only

Correct response: wear gown, gloves, and mask Explanation: RSV is highly contagious and is spread through direct contact with infectious secretions via hands, droplets, and fomites. Gown, gloves, and mask should be worn for care of the infant to prevent the spread of infection, in addition to proper hand washing between clients.

A nurse at the family clinic receives a call from the parent of a 5-week-old infant. The parent states that the child was diagnosed with colic at the last checkup. Unfortunately, the symptoms have remained the same. What reinforcement teaching is appropriate? Select all that apply: 1. Position the infant on his/her back after feedings. 2. Soothe the child by humming and rocking. 3. Immediately bring the infant to the emergency department. 4. Burp the infant adequately after feedings. 5. Provide small, frequent feedings to the infant. 6. Offer a pacifier if it is not time for the infant to eat.

Correct response; 2. Soothe the child by humming and rocking. 4. Burp the infant adequately after feedings. 5. Provide small, frequent feedings to the infant. 6. Offer a pacifier if it is not time for the infant to eat. Explanation: Colic consists of recurrent paroxysmal bouts of abdominal pain and is fairly common in infants. It usually disappears by age 3 months. Rocking, riding in a car, humming, and offering a pacifier may be used to comfort the infant. Decreasing gas formation by frequent burping, giving smaller feedings more frequently, and positioning the infant in an upright seat are also appropriate teaching. The infant should not be positioned on the back after feedings because this increases gas formation. Colic is a manageable condition in the home. The infant does not need to be taken to the emergency department unless the symptoms worsen, a temperature accompanies the symptoms, or vomiting occurs with the symptoms.