pets exam 2
A parent brings a 2-week-old infant to the clinic because the infant continually regurgitates. Chalasia, an incompetent cardiac sphincter, is suspected. What instructions should the nurse give the parent? 1 Keep the infant in an upright position after feedings. 2 Prevent the infant from crying for prolonged periods. 3 Keep the infant in the prone position after each feeding. 4 Ensure that the infant drinks a full bottle of formula at each feeding.
1
An infant has developmental dysplasia of the hip. What clinical finding should the nurse expect to note during an assessment? 1 Apparent shortening of one leg 2 Limited ability to adduct the affected leg 3 Narrowing of the perineum with an anal stricture 4 Inability to palpate movement of the femoral head
1
A nurse in the pediatric clinic is assessing an 11-month-old infant with iron-deficiency anemia. The infant's hemoglobin is 8 g/dL (80 mmol/L). What does the nurse expect to observe when assessing the infant? 1 Pallor 2 Tremors 3 Cyanosis 4 Spasticity
1 Paleness occurs because the hemoglobin within the erythrocytes gives them their red color; a low hemoglobin level in the blood results in pallor.
What is the priority nursing action when a 3-month-old infant is receiving intravenous (IV) fluids by way of an antecubital vein? 1 Monitoring for infiltration behind the infant's elbow 2 Applying arm boards to prevent bending at the elbows 3 Checking both of the infant's pupils for dilation every hour 4 Telling the parents why they cannot hold the infant during IV therapy
2
A nurse has just administered an immunization injection to a 2-month-old infant. What instructions should the nurse give the parent if the infant has a reaction? 1 Give aspirin for pain; if swelling at the injection site develops, call the healthcare provider. 2 Apply heat to the injection site for the first day after the injection; apply ice if the arm is inflamed. 3 Give acetaminophen for fever; call the healthcare provider if the child exhibits marked drowsiness or seizures. 4 Apply ice to the injection site if soreness develops; call the healthcare provider if the child comes down with a fever.
3
What clinical finding does a nurse expect when assessing a 4-month-old infant with gastroenteritis and moderate dehydration? 1 Urine output of 50 mL/hr 2 Depressed anterior fontanel 3 History of allergies to certain formulas 4 Capillary refill time of less than 2 seconds
3
A nurse confirms that a 9-month-old infant's immunization schedule is up to date. Which immunization will the infant receive at 15 months of age? 1 Hepatitis B (HepB) 2 Polio vaccine 3 Tetanus toxoid 4 Measles, mumps, and rubella (MMR
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A nurse is caring for an infant with developmental dysplasia of the hip. What is the priority intervention for this child? 1 Flexion of the hip 2 Extension of the hip 3 Adduction of the hip 4 Abduction of the hip
4
After a cleft lip repair a nurse places elbow restraints on the infant. The parents ask the nurse, "Why does our child have to have restraints?" How should the nurse respond? 1 "They're used routinely on infants who have had lip surgery." 2 "Legally we're required to put them on infants after lip surgery." 3 "The staff can't be with your baby continuously to prevent touching of the mouth." 4 "Because we're keeping the arms straight, your baby won't be able to touch the mouth."
4
The parents of a 6-week-old infant who was born without an immune system ask the nurse why their baby is still so healthy. What is the best response by the nurse? 1 Exposure to pathogens during this time can be limited. 2 Some antibodies are produced by the infant's colonic bacteria. 3 Bottle feeding with soy formula has boosted the immune system. 4 Antibodies are passively received from the mother through the placenta and breast milk.
4
An infant who has undergone surgery for hypertrophic pyloric stenosis (HPS) is being bottle fed by the mother. What should the nurse teach the mother about feedings to decrease the chance of the infant vomiting? 1 Start with small, frequent feedings. 2 Rock for 20 minutes after a feeding. 3 Keep the infant awake for 30 minutes after feeding. 4 Position the infant flat on the right side during feedings
1
The mother of an infant who just underwent cleft lip repair tells the nurse, "He seems restless. May I hold him?" What information influences the nurse's response? 1 Holding may meet needs and reduce tension on the suture line. 2 Sedation limits activity and decreases tension on the suture line. 3 Handling may increase irritability, causing tension on the suture line. 4 Arm movements cannot be controlled, placing tension on the suture line
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A nurse is caring for a 9-month-old infant with gluten-induced enteropathy. What common term for this disorder should the nurse use when discussing the infant's diagnosis with the parents? 1 Megacolon 2 Celiac disease 3 Cystic fibrosis 4 Intussusception
2
A nurse is trying to soothe a 2-month-old infant who is crying. What is the best way to soothe a young infant? 1 Offering the infant a bottle of diluted juice 2 Holding and rocking the infant in a quiet room 3 Changing the diaper before returning the infant to the crib 4 Wrapping a blanket around the infant and placing him in a supine position
2
An infant is found to have hydrocephalus. Which assessment finding alerts the nurse to suspect increasing intracranial pressure? 1 Sunken eyes 2 Projectile vomiting 3 Depressed fontanels 4 Narrowing pulse pressure
2
An infant is to be discharged after surgery for pyloric stenosis. What instructions should the nurse give the parents? 1 "Offer the baby creamy cereal at each feeding, and follow it with a regular formula." 2 "Hold the baby while continuing to feed a regular formula slowly and burp frequently." 3 "Allow the baby to drink about 1 oz (30 mL) of a regular formula per hour for a week, and progress slowly to larger amounts." 4 "Place the baby on the right side in the crib during feedings with regular formula, and minimize handling for 2 hours after feeding."
2
How can a nurse best soothe a hospitalized infant who appears to be in pain? 1 Feeding the infant 2 Holding the infant 3 Playing soft music in the room 4 Providing a quiet environment
2
What is the priority nursing intervention for a 6-month-old infant with bronchiolitis? 1 Discouraging parental visits to conserve energy 2 Monitoring skin color, anterior fontanel, and vital signs 3 Wearing gown, cap, mask, and gloves when rendering care 4 Promoting stimulating activities to meet developmental needs
2
A nurse is caring for a 9-month-old infant with severe dehydration. What does the nurse expect to note while completing a physical assessment of this infant? 1 Frothy stools 2 Weak, rapid pulse 3 Pale, copious urine 4 Bulging anterior fontane
2 A weak, rapid pulse is an expected adaptation with a state of severe dehydration because of hypovolemia. Children with untreated cystic fibrosis and celiac disease have frothy stools. There is no indication that this infant has either of these disorders. Severe dehydration results in decreased urine output and concentrated urine. One of the signs of dehydration in an infant is a sunken, not bulging, anterior fontanel.
The mother of a 4-month-old infant weighing 11 lb (5 kg) asks the nurse how much formula is required per day now that her baby has been weaned from the breast. The recommended caloric intake is 108 kcal/kg, and the formula contains 20 kcal/oz (20 kcal/30 mL). How much formula should the nurse tell the mother to give to her infant each day? 1 21 oz (630 mL) 2 27 oz (810 mL) 3 33 oz (990 mL) 4 39 oz (1170 mL)
2 The infant weighs 11 lb (11/2.2 = 5 kg). An infant's daily caloric need is 108 kcal/kg body weight. 108 kcal × 5 kg = 540 kcal/day; because there are 20 kcal/oz, 540 ÷ 20 = 27 oz (20 kcal/30 mL, 540 ÷ 20 X 30 mL = 810 mL) .
A parent brings a 2-month-old infant with Down syndrome to the pediatric clinic for a physical and administration of immunizations. Which clinical finding should prompt the nurse to perform further assessment? 1 Flat occiput 2 Small, low-set ears 3 Circumoral cyanosis 4 Protruding furrowed tongue
3
Hydrocephalus develops in an infant who was born with a meningomyelocele, and a ventriculoperitoneal shunt is inserted. What nursing intervention is most important in this infant's care during the first 24 hours after surgery? 1 Placing in the high Fowler position 2 Administering the prescribed sedative 3 Positioning on the same side as the shunt 4 Monitoring for increasing intracranial pressure
4
The parent of a newborn asks a nurse why, except for hepatitis B vaccine, the immunization schedule does not start until the infant is 2 months old. How should the nurse respond? 1 "A newborn's spleen can't produce efficient antibodies." 2 "Infants younger than 2 months are rarely exposed to infectious disease." 3 "The immunization will attack the infant's immature immune system and cause the disease." 4 "Maternal antibodies interfere with the development of active antibodies by the infant when immunized."
4 Passive antibodies received from the mother will be diminished by age 8 weeks and will no longer interfere with the development of active immunity to most communicable diseases.
