PEDIATRIC HOMEWORK A INFANT
A 9-month-old infant is admitted with diarrhea and dehydration. The nurse plans to assess the child's vital signs frequently. Which other action provides important assessment information?
measuring the infant's weight
During a visit to the clinic, a mother who's breast-feeding her 2-month-old infant expresses concern over the infant's bowel movements. Which statement by the mother would lead the nurse to believe that the infant's bowel movements are normal?
Breast-fed infants typically have soft, bright yellow or light green stools with no offensive odor. Formula-fed infants typically have pale yellow, semi-formed stools with a strong odor. A neonate's first stools typically are dark green to black, sticky, and odorless (representing meconium, usually present for the first 3 days). By the fourth day, yellowish green transitional stools appear. Green, watery stools indicate diarrhea.
When teaching the parents of a child diagnosed with tetralogy of Fallot about the cardiac defects involved with this condition, which defects should the nurse describe? Select all that apply.
Tetralogy of Fallot involves four defects: right ventricular hypertrophy, ventricular septal defect, overriding aorta, and pulmonary stenosis.
A nurse has received report on her clients and notices that they're of varying ages. To prepare for the shift, the nurse reviews Erik Erikson's five stages of psychosocial development. Place the stages in chronological order from infancy to adolescence. Use all options. Trust versus mistrust Autonomy versus shame and doubt Initiative versus guilt Identity versus role confusion Industry versus inferiority
Trust versus mistrust Autonomy versus shame and doubt Initiative versus guilt Industry versus inferiority Identity versus role confusion
A client presents with a congenital heart defect and increased pulmonary blood flow. Which signs or symptoms will alert the nurse that congestive heart failure is occurring? Select all that apply. polyuria tachypnea with feeding coarse breath sounds coughing
coughing tachypnea with feeding coarse breath sounds
A nurse is teaching the parents of an infant with heart failure about the administration of furosemide. The parents will be administering the medication to the infant at home. What is the most important information for the nurse to teach the parents about the drug administration?
Correct response: "It's important to call the clinic if there is no urine output in 8 hours." Explanation: Furosemide is nephrotoxic, so parents should be taught to notify the healthcare provider if there is no urine output in 8 hours.
A nurse is caring for an infant with an intravenous (IV) line in the antecubital space. Which findings would cause the nurse to intervene? Select all that apply.
Correct response: antecubital area that is cool to the touch infant bending his arm freely edematous site Explanation: The nurse should use a padded board because it is adequate to secure the extremity. A jacket restraint is not needed when the nurse needs only to secure the arm with the IV. 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 IV will infiltrate or be dislodged by the infant.
A nurse at the family clinic receives a call from the mother of a 5-week-old infant. The mother states that her child was diagnosed with colic at the last checkup. Unfortunately, the symptoms have remained the same. Which teaching instructions are appropriate? Select all that apply.
Correct response: Soothe the child by humming and rocking. Burp the infant adequately after feedings. Provide small but frequent feedings to the infant. 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.
Which clinical manifestations would lead the nurse to suspect that an infant has hypothyroidism? Select all that apply.
Correct response: cool extremities muscle weakness lethargy Explanation: Hypothyroidism is a disorder in which the levels of active thyroid hormone are decreased. Clinical manifestations include cool extremities, mottling, lethargy, constipation, muscle weakness, and a hoarse cry. Hyperthyroidism occurs when thyroid hormone levels are increased. Clinical manifestations include increased appetite, goiter, irritability, prominent eyes, and tachycardia
A parent is playing with an infant, who's sitting securely alone on the floor of the clinic. The parent hides a toy behind the back and the infant looks for it. What age should the nurse estimate the infant to be?
Correct response: 10 months Explanation: The nurse would estimate that the infant is 10 months old because an infant this age can sit alone and understands object permanence, so would look for the hidden toy. Between ages 2 and 4 months, children can't sit securely alone. At age 8 months, children can sit securely alone but don't understand the permanence of objects.
The unlicensed assistive personnel (UAP) obtained vital signs on a 7-month-old infant and recorded the peripheral pulse as 85 beats/minute. The RN immediately reassesses the child's pulse and discovers the pulse is 115 beats/minute. What should the nurse teach the UAP about obtaining an accurate heart rate in an infant?
Correct response: "To assess a pulse in children, always assess the apical pulse." Explanation: The apical pulse is the best location for evaluating the pulse of an infant younger than age 1, and a normal heart rate in this age group while awake is 100-160 beats/minute. The radial artery may not be easily palpable, causing missed beats and a potentially inaccurately low result. Providing a list of normal heart rates does not demonstrate the UAP knows how to obtain the pulse rate correctly. Taking the blood pressure first may irritate the child and cause crying, which can affect the accuracy of the heart rate assessment.
A mother of a hospitalized infant appears anxious and displays anger with the staff. Which response by the nurse is most appropriate?
Correct response: "You seem upset. Having your child hospitalized must be difficult." Explanation: Acknowledging the mother's feelings and recognizing that it's difficult to cope with a hospitalized child allows the mother to express her feelings. Asking the mother if she wants to talk about her concerns only allows a yes or no response; it does not provide an opportunity for the mother to share or vent. The mother may want to speak to a chaplain, but asking does not address the issue of being fearful and angry. Additionally, that action involves the nurse delegating the problem to someone else without seeking out the root of the problem. Saying "your baby will be better soon" only gives false reassurance and does not address the mother's immediate needs.
A nurse walks into the room just as a 10-month-old infant places an object in his mouth and starts to choke. After opening the infant's mouth, what should the nurse do next to clear the airway?
Correct response: Deliver back slaps and chest thrusts. Explanation: The nurse should use mechanical force—back slaps and chest thrusts—in an attempt to dislodge the object. Blind finger sweeps are not appropriate in infants and children because the foreign body may be pushed back into the airway. Subdiaphragmatic abdominal thrusts are not used for infants aged 1 year or younger because of the risk of injury to abdominal organs. If the object is not visible when opening the mouth, time is wasted in looking for it. Action is required to dislodge the object as quickly as possible.
Parents bring a child to the clinic who has not been eating or drinking well for the last few days. What action should the nurse take first to assess the child's overall hydration status?
Correct response: Weigh the child. Explanation: When implementing nursing care, the nurse should complete any noninvasive procedures before invasive ones. Therefore, the first step the nurse should take is to weigh the child. A decrease in body weight gives the most accurate information about the infant's hydration status. Monitoring vital signs would be the next step in the assessment process. The blood pressure reading would yield information about hypotension. A urinalysis would provide information about urine osmolality and specific gravity of the urine, which indicates dehydration. Obtaining electrolytes would provide information about electrolyte disturbances, not strictly about hydration.
The nurse is caring for a neonate 4 hours after birth who has not passed meconium. When the nurse is assessing the neonate, the "wink reflex" cannot be elicited, and a membrane filled with meconium is observed bulging through the anus. Which of the following defects does the nurse suspect has occurred in utero?
Correct response: imperforate anus Explanation: An imperforate anus is discovered at birth when inspection of a newborn's anal region reveals no anus or a membrane filled with black meconium that protrudes from the anus. The condition is also suspected if it is impossible to insert a rubber catheter into the rectum. A "wink" reflex (touching the skin near the rectum should make the anus contract) cannot be elicited if sensory nerve endings in the rectum are not intact. Intussusception is a telescoping of a portion of bowel into another portion causing obstruction. A meconium plug is a hard portion of meconium that completely blocks the intestinal lumen. Choanal atresia is a congenital defect where the nasal passages are blocked.
The nurse is about to assess an infant's thyroid gland. In which position should the nurse place an infant to best examine the thyroid gland?
Correct response: supine Explanation: The nurse should place the infant in the supine position on the caregiver's lap because it hyperextends the infant's neck, promoting thyroid palpation. A prone position wouldn't allow an adequate area for palpation. A sitting position is appropriate when assessing the thyroid gland of an older child or an adult. Semi-Fowler's position does not allow for hyperextension of the neck.
Which action(s) should the nurse take prior to administering an oral medication to an infant? Select all that apply. Have the mother hold the infant. Ensure that it is the correct medication. Verify that it is the correct dose. Verify the infant's name. Check the infant's pulse.
Ensure that it is the correct medication. Verify that it is the correct dose. Verify the infant's name.
An infant goes into cardiac arrest. While conducting resuscitation, the team notes critical supplies are missing because the cart was not restocked properly by the nurses after an earlier arrest. The baby sustains brain damage as a result of delays in obtaining needed supplies. How does the nurse manager address this situation?
Hold the nurses responsible because hospital procedure was not followed. Agency and hospital policies and procedures establish standards of care. If a nurse deviates from the standard, liability could result if an injury is sustained. In this case, the baby sustained brain damage because the nurses failed to follow the procedure for restocking the crash cart immediately after a code. The nurse needs to report to the pharmacy that the medications need to be restocked. The pharmacist cannot be blamed or held liable if they were not notified. The manager should not tell the nurses they will not be held liable. There is not evidence that current practice needs to be changed, just followed consistently.
