Prep U Infant

The charge nurse observes that a nurse caring for a very sick infant is making inappropriate remarks and acting bizarrely. What is the first

Remove this nurse from the client assignment. (Because client safety is the priority, the most appropriate first action by the charge nurse is to remove the nurse who is acting bizarrely from the client assignment. The charge nurse would next report the behavior to the supervisor. The supervisor nurse should talk to the nurse and determine the basis for the behavior. Depending on the findings, the employee may be required to take a drug test or security may become involved. )

When assessing a 2-month-old infant, the nurse feels a "click" when abducting the infant's left hip. What should the nurse do next?

Check the lengths of the femurs to determine if they are equal. (The "click" the nurse feels when abducting the femur is made by the head of the femur as it slips into the acetabulum. This is Ortolani's sign and indicates a dislocated hip. This is not a normal finding for a 2-month-old. The nurse needs to gather additional information by checking for unequal leg lengths and asymmetry of the gluteal and thigh folds. Once the nurse has obtained additional assessment information, the nurse would notify the health care provider (HCP). Usual medical treatment involves keeping the hip joint in an abducted position in a Pavlik harness. The goal of treatment is to keep the head of the femur centered in the acetabulum. Treatment needs to begin as soon as possible. Usually, the earlier treatment is started, the better the outcome)

An infant is hospitalized for treatment of inorganic failure to thrive. Which nursing action is most appropriate for this child?

Maintaining a consistent, structured environment (The nurse caring for an infant with inorganic failure to thrive should strive to maintain a consistent, structured environment because it reinforces a caring feeding environment. Encouraging the infant to hold a bottle would reinforce an uncaring feeding environment. The infant should receive social stimulation rather than be confined to bed rest. The number of caregivers should be minimized to promote consistency of care.)

A parent asks, "How should I bathe my baby now that he has had surgery for his inguinal hernia?" Which instruction should the nurse give the mother?

"Give him a sponge bath daily for 1 week." (The incision must be kept as clean and dry as possible. Therefore, daily sponge baths are given for about 1 week postoperatively. Cleaning the infant's face and diaper area should occur at least daily and continuously, not limited to a 2-week period. Because this type of surgery results in a wound that heals through primary intention, the skin will heal and cover the wound in 2 to 3 days. Therefore, it is not necessary to use sterile gauze to cleanse the incision; clean technique is acceptable. Because the incision must be kept as clean and dry, full tub baths are inappropriate. )

During the nurse's assessment, the newborn wakes and is in a quiet-alert state. The nurse counts the apical pulse to be 157 beats per minute. Which of the following is the most appropriate nursing action?

Document this finding as on the high end of the normal range and plan to reassess. (Heart rates can be as fast as 180 bpm, but the normal range for a newborn heart rate is 110-160 bpm. Thus, the newborn's heart rate of 157 bpm is on the high end of the normal range, but still within the normal range. It would be appropriate to reassess the client's heart rate because newborn heart rates can fluctuate depending on the state of consciousness/wakefulness, hunger, temperature, and especially if the newborn is moving or startled. It would be inappropriate to call the pediatrician or to notify the charge nurse at this time because the value is currently within the normal range.)

After surgery to repair a cleft lip, an infant has a Logan bow in place. Which postoperative nursing action is appropriate?

Holding the infant semi-upright during feedings (Holding the infant semi-upright during feedings is appropriate because it helps prevent aspiration. The Logan bow 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 the abdomen could lead to disruption of the suture line if the infant rubs the face.)

A nurse is assessing an infant for signs of increased intracranial pressure (ICP). What is the earliest sign of increased ICP in an infant?

Irritability (An infant with increased ICP is commonly fussy, irritable, and restless at first as a result of a headache cause by the ICP. Vomiting occurs later. Papilledema is a late sign of increased ICP that may not be evident. Changes in vital signs occur later; pressure on the brainstem slows pulse and respiration)

A 4-month-old infant has been carried into the emergency department after falling off his parents' bed and hitting his head on the floor. What should the nurse do next?

Move the family to an area where an assessment can be completed and call for a physician. (A head injury in an infant can be extremely serious. The nurse's priority should be to move the infant and family to an area where assessment and treatment can occur. Triaging the infant and having the parents wait for evaluation by a physician is inappropriate because of the potential seriousness of the injury. Although increased intracranial pressure can result from head trauma, it's unlikely that inserting a VP shunt would be the first treatment. The fact that the child was left unattended in an unsafe location is a significant safety issue, but notifying child protective services isn't a priority at this time)

A parent tells the nurse that their 8-month-old infant is anxious. Which suggestion by the nurse is most appropriate to help the parent lessen anxiety in the infant?

Talk quietly to the infant while he is awake. (Infants are sensitive to stress in their caretakers. The best way to handle an anxious infant is to talk quietly, thereby soothing the infant. Limiting holding of the infant to feeding periods interferes with meeting the infant's needs for close contact, possibly compromising his ability to develop trust. Playing music in the room for most of the day and night will make it difficult for the infant to differentiate days from nights. Having a friend take the infant for several days will not necessarily take care of the problem because when the infant returns to the parents, the same behaviors will recur unless the parents makes some changes)

In which of the following parts of the body should the nurse administer an intramuscular injection to a 6-month-old infant?

The lateral middle third of the thigh between the greater trochanter and the knee (The appropriate site to give an injection to an infant is the vastus lateralis. The dorsogluteal, ventrogluteal, and deltoid muscles are areas for older children and adults.)

An infant with an upper respiratory tract infection has stridor. Which of the following should be the nurse's immediate action? Select all that apply.

• Administering oxygen • Notifying the healthcare provider • Getting emergency equipment to the bedside (An infant with stridor could have airway obstruction. The nurse should notify the primary healthcare provider, get emergency equipment, and administer oxygen. Parent instruction and repositioning the infant's neck are not indicated.)

An infant is brought to the clinic with a possible diagnosis of Wilms' tumor. When obtaining the health history, which question should the nurse consider a priority to ask the mother?

"Did the healthcare provider find a mass in the abdominal area?" (The most common sign of Wilms' tumor is a painless, palpable abdominal mass, sometimes accompanied by an increase in abdominal girth. Projectile vomiting after a feeding is found with pyloric stenosis. A reddish, jelly-like bowel movement referred to as "currant jelly" is seen in intussusception. A pulsating anterior fontanel is a normal finding.)

Which action should a nurse include in the care plan for a 2-month-old infant with heart failure?

Allow the infant to rest before feeding. (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 underwent surgery to remove a myelomeningocele. The infant has bulging fontanels. Which of the following is the nurse's best action?

Notify the healthcare provider (Bulging fontanels in an infant may indicated increased intracranial pressure, a possible postoperative complication. Calming the infant, teaching the parent, and repositioning the infant will not address the underlying problem of increased intracranial pressure within the skull. Calling the healthcare provider is indicated)

When teaching the mother of a child diagnosed with phenylketonuria (PKU) about its transmission, the nurse should use knowledge of which factor as the basis for the discussion?

autosomal recessive gene (PKU is caused by an inborn error of metabolism. It is an autosomal recessive disorder that inhibits the conversion of phenylalanine to tyrosine. A form of Down syndrome, trisomy 21, is an example of a disorder caused by chromosomal translocation. Cri du chat is an example of a disorder caused by chromosomal deletion. Hemophilia A is an example of a disorder caused by an X-linked recessive gene.)

The mother of an infant with myelomeningocele asks if her baby is likely to have any other defects. The nurse responds based on the understanding that myelomeningocele is commonly associated with which disorder?

excessive cerebrospinal fluid within the cranial cavity (Excessive cerebrospinal fluid in the cranial cavity, called hydrocephalus, is the most common anomaly associated with myelomeningocele. Microcephaly, an abnormally small head, is associated with maternal exposure to rubella or cytomegalovirus. Anencephaly, a congenital absence of the cranial vault, is a different type of neural tube defect. Overriding of the sutures, possibly a normal finding after a vaginal birth, is not associated with myelomeningocele)

A newborn who had a surgical repair of a tracheoesophageal fistula (TEF) is started on oral feedings. What should the nurse include in the teaching plan for the parent about oral feedings?

They are best planned in conjunction with observations of the infant's behavior. ( When initiating oral feedings after surgical repair of a TEF, it is best to follow a plan of care in conjunction with observation of the infant's needs and behavior known as cue-based feedings. When sticking to a strict feeding schedule that overlooks the infant's readiness, plans are likely to be unsatisfactory and are more likely to meet the nurse's needs rather than the infant's needs. After a surgical procedure, infants initially tolerate small amounts of fluids offered more frequently better than larger amounts offered less often. Smaller amounts cause less bloating as the infant becomes used to feeding again. Although infants accept feedings more readily from their mother or from someone who feeds the infant repeatedly, the priority is to meet the infant's nutritional needs based on the infant's behavior)

A 10-month-old child with recurrent otitis media is brought to the clinic for evaluation. To help determine the cause of the child's condition, the nurse should ask the parents:

"Do you give the baby a bottle to take to bed?" (In a young child, the eustachian tube is relatively short, wide, and horizontal, promoting drainage of secretions from the nasopharynx into the middle ear. Therefore, asking if the child takes a bottle to bed is appropriate because drinking while lying down may cause fluids to pool in the pharyngeal cavity, increasing the risk of otitis media. Asking if the parent noticed earwax, or cerumen, in the external ear canal is incorrect because wax doesn't promote the development of otitis media. During shampooing, water may become trapped in the external ear canal by large amounts of cerumen, possibly causing otitis external (external ear inflammation) as opposed to internal ear inflammation. Asking if the infant can combine two words is incorrect because a 10-month-old child isn't expected to do so)

A 1-year-old child is admitted to the hospital with sickle cell crisis. Which intervention will be a part of the child's plan of care?

IV fluid therapy (During a sickle cell crisis, increasing the transport and availability of oxygen to the body's tissues is paramount. Administering a high volume of IV fluid and electrolytes to help compensate for the acidosis resulting from hypoxemia associated with sickle cell crisis is one way to accomplish this. Fluid administration also helps overcome dehydration, a possible predisposing factor common in children with sickle cell crisis. Iron therapy is contraindicated for this condition. Exchange transfusions are used only in certain situations, such as severe hyperbilirubinemia. Small amounts of blood are removed from the infant and replaced with whole blood. This helps to correct the anemia and lower bilirubin levels. Although anticoagulants have been suggested, they are not included in the usual treatment of sickle cell crisis. )

The nurse is evaluating an infant for auditory ability. What is the expected response in an infant with normal hearing?

blinking and stopping body movements when sound is introduced (In response to hearing a noise, normally hearing infants blink or startle and stop body movements. Shy and withdrawn behaviors are characteristic of older children with hearing impairment. Squealing occurs in 90% of infants by age 4 months. Most infants can say "da-da" by age 9 months)

The nurse judges that the mother has understood the teaching about care of an infant with colic when the nurse observes the mother doing which action?

burping the infant during and after the feeding (Infants with colic should be burped frequently during and after the feeding. Much of the discomfort of colic appears to be associated with the presence of air in the stomach and the intestines. Frequent burping helps to relieve the air. Infants with colic should be held fairly upright while being fed, to help air rise. The preferred position for burping the infant with colic is to hold the infant at the mother's shoulder so that the infant's abdomen lies on the shoulder. This position causes more pressure to be exerted on the infant's abdomen, leading to a more forceful burp. The child should be placed in an infant seat after feedings)

A 6-month-old infant is brought to the clinic. The mother reports the infant has been lethargic. The infant's anterior fontanel is sunken. What other assessment data are a priority for the nurse to collect?

Number of wet diapers the in the last 24 hours (A sunken fontanel indicates dehydration. The nurse should assess the number of wet diapers the infant has had in the past 24 hours. Number of stools may indicate diarrhea, but is less accurate in determining dehydration status. Number of normal hours slept at this age is variable and could be misleading without normal context for this infant. As well, lethargy with a sunken fontanel is related to dehydration as opposed to a neurological issue. Skin color and cap refill are more essential with a cardiac issue)

A nurse should take action when a healthy 3-month-old infant is:

being fed formula that isn't mixed according to the manufacturer's instructions. (Incorrectly mixed formula can cause an infant to develop severe electrolyte and nutrition imbalances. This safety hazard necessitates immediate attention. Placing a 3-month-old infant in a rear-facing car seat is appropriate. Although an infant sleeping in a cardboard box on the floor may be a concern, it isn't an immediate safety hazard. An infant being put to sleep with a pacifier isn't a safety concern)

A 5-month-old infant is brought to the clinic by his parents because he "cries too much" and "vomits a lot." The infant's birth weight was 6 lb, 10 oz (3,000 g), and his current weight is 7 lb, 4 oz (3,289 g), falling below the 5th percentile on a standard growth chart. Which data should the nurse identify as the priority?

feeding pattern (Because the infant falls below the 5th percentile on a standard growth chart, the nurse should consider failure to thrive, a term applied to an infant who is not growing at an acceptable rate. Information about feeding patterns, including types and amounts of food, is needed to determine the cause of failure to thrive. If a child does not receive sufficient calories, growth slows. Whether or not the infant has received regular checkups is important but not the priority because that information alone does not provide evidence or substantiation about the infant's growth patterns. The infant's pattern of weight gain is important but not the priority. Rather, the infant's pattern of weight gain provides valuable and useful information over a period of time. Information about family dynamics is important to provide data about family stresses that may affect or help explain the infant's failure to thrive. However, it is not the priority. This information needs to be viewed in conjunction with the infant's feeding patterns to gain a complete picture. )