CH 5

A nurse is caring for a newborn whose chest X-ray reveals marked hyperaeration mixed with areas of atelectasis. The infant's arterial blood gas analysis indicates metabolic acidosis. For which dangerous condition should the nurse prepare when providing care to this newborn?

meconium aspiration syndrome The nurse should assess for meconium aspiration syndrome in the newborn. Meconium aspiration involves patchy, fluffy infiltrates unevenly distributed throughout the lungs and marked hyperaeration mixed with areas of atelectasis that can be seen through chest X-rays. Direct visualization of the vocal cords for meconium staining using a laryngoscope can confirm aspiration. Lung auscultation typically reveals coarse crackles and rhonchi. Arterial blood gas analysis will indicate metabolic acidosis with a low blood pH, decreased PaO2, and increased PaCO2. Newborns with choanal atresia, diaphragmatic hernia, and pneumonia do not exhibit to exhibit these manifestations.

A newborn is passing greenish-black stool of tarry consistency. The nursing student correctly identifies this type of stool as which of the following? a) stool of a formula-fed newborn b) meconium stool c) stool of a breast-fed newborn d) transitional stool

meconium stool Correct Explanation: Meconium is a newborn's first stool. It is composed of amniotic fluid, shed mucosal cells, intestinal secretions, and blood. Breast-fed newborns will pass stools that are yellow-gold, loose, and stringy to pasty in consistency. A formula-fed newborn will have stools that are yellow, yellow-greeen, or greenish and loose, pasty, or formed in consistency based upon the type of formula.

The perinatal nurse is assessing a large-for-gestational age infant born by breech birth and notes that the infant is irritable and does not move the right arm. For what would the nurse assess?

midclavicular fracture Midclavicular fractures most often occur during births of newborns with macrosomia. The newborn is irritable and does not move the arm on the affected side either spontaneously or when the Moro reflex is elicited. A brachial plexus injury usually presents with the extremity adducted and internally rotated with absent shoulder movement. Phrenic nerve palsy is not associated with birth injuries and is caused by lesions along the phrenic nerve. The newborn does not demonstrate signs of cranial nerve trauma, which would be evident in the face.

A nurse is working with a child who has spina bifida. Which nursing goal for this child would have the highest priority?

preventing infection The highest priority nursing goal is preventing infection because of the vulnerability of the myelomeningocele sac. Promoting comfort is important but not as high a priority because the child does not usually have severe pain with this diagnosis. Reducing anxiety and teaching are lower priorities; physical is a higher priority than psychosocial.

A 17-year-old child has been admitted with complications of anorexia nervosa. What diagnostic tests can be anticipated in the plan of care/treatment?

• Complete blood cell count • Metabolic panel Anorexia nervosa is characterized by dramatic weight loss as a result of decreased food intake and sharply increased physical exercise. Complications of anorexia include fluid and electrolyte imbalance, decreased blood volume, cardiac arrhythmia, esophagitis, rupture of the esophagus or stomach, tooth loss, and menstrual problems. A metabolic panel would highlight alterations in electrolyte status. Electrolyte imbalances are also associated with cardiac arrhythmia. Reduced dietary intake may result in anemia. This will be noted in the hemoglobin level. An alteration in blood volume will be reflected in the hematocrit level

A nursing student asks the instructor why are all the babies in the nursery are wrapped up like it is freezing and are wearing little hats. Which would be the best response? a) "Newborns lose body heat and need to be kept warm until their temperature stabilizes." b) "Studies show that newborns like the extra warmth." c) "They look so cute like that." d) "That's how we have always done it and it seems to work."

"Newborns lose body heat and need to be kept warm until their temperature stabilizes." Correct Explanation: Nurses provide an appropriate environment to help newborns maintain thermal stability. Newborns lose body heat easily and need to kept warm until their temperature stabilizes. The other answers are not adequate and do not explain the correct rationale.

A group of nursing students is discussing hydrocephalus. Which statement made by the students related to the noncommunicating type of congenital hydrocephalus is the most accurate?

"There is an obstruction that keeps cerebrospinal fluid from passing between the ventricles and the spinal cord." In the noncommunicating type of congenital hydrocephalus, an obstruction occurs, and CSF is not able to pass between the ventricles and the spinal cord. The blockage causes increased pressure on the brain or spinal cord. In the communicating type of hydrocephalus, no obstruction of the free flow of CSF exists between the ventricles and the spinal theca; rather, the condition is caused by defective absorption of CSF. There is no concern of decreased production of CSF and no opening between the ventricles and spinal cord in hydrocephalus

A mother is concerned because her daughter has lost 8 ounces 3 days after birth. What response by the nurse is appropriate? a) "Your baby needs to be checked for a viral illness." b) "Your baby is probably just dehydrated." c) "This is a normal and expected finding." d) "You need to give your baby formula since she has lost weight during breastfeeding."

"This is a normal and expected finding." Correct Explanation: The infant has a 5-10% loss of birth weight during the first few days of life as the body looses excess fluid and has limited food intake. You would not tell the new mother that her infant needs to be checked for a viral illness, this is inappropriate because if the infant were ill you would have no way of knowing if it was a viral or a bacterial disease process. Option C is incorrect as weight loss in a newborn is a normal finding. Option D is incorrect as a new breastfeeding mother should not supplement feedings with formula.

A nursing instructor is teaching about changes the newborn must make to survive outside of the uterus. The instructor realizes that further teaching is needed when a student says which of the following? a) "When the umbilical cord is clamped the first breath is taken." b) "When the baby is ready to leave the uterus, it takes its first breath." c) "The first breath is taken when the baby is stimulated by a slight slap." d) "When the umbilical cord is clamped the lungs begin to function."

"When the baby is ready to leave the uterus, it takes its first breath." Correct Explanation: Changes in circulation begin immediately at birth as the fetus separates from the placenta. When the umbilical cord is clamped, the first breath is taken and the lungs begin to function.

While caring for a preterm newborn receiving oxygen therapy, the nurse monitors the oxygen therapy duration closely based on the understanding that the newborn is at risk for which of the following? A)Retinopathy of prematurity B)Metabolic acidosis C)Infection D)Cold stress

A)Retinopathy of prematurity

37. Which immunization should be given with caution to children infected with human immunodeficiency virus (HIV)? a. Influenza b. Varicella c. Pneumococcal d. Inactivated poliovirus (IPV)

ANS: B The children should be carefully evaluated before being given live viral vaccines such as varicella, measles, mumps, and rubella. The child must be immunocompetent and not have contact with other severely immunocompromised individuals. Influenza, pneumococcal, and inactivated poliovirus (IPV) are not live vaccines.

43. An adolescent will receive a bone marrow transplant (BMT). The nurse should explain that the bone marrow will be administered by which route? a. Bone grafting b. Bone marrow injection c. IV infusion d. Intra-abdominal infusion

ANS: C Bone marrow from a donor is infused intravenously, and the transfused stem cells will repopulate the marrow. Because the stem cells migrate to the recipients marrow when given intravenously, this is the method of administration.

21. The nurse is conducting a staff in-service on childhood blood disorders. Which describes the pathology of idiopathic thrombocytopenic purpura? a. Bone marrow failure in which all elements are suppressed b. Deficiency in the production rate of globin chains c. Diffuse fibrin deposition in the microvasculature d. An excessive destruction of platelets

ANS: D Idiopathic thrombocytopenic purpura is an acquired hemorrhagic disorder characterized by an excessive destruction of platelets, discolorations caused by petechiae beneath the skin, and a normal bone marrow. Aplastic anemia refers to a bone marrowfailure condition in which the formed elements of the blood are simultaneously depressed. Thalassemia major is a group of blood disorders characterized by deficiency in the production rate of specific hemoglobin globin chains. Disseminated intravascular coagulation is characterized by diffuse fibrin deposition in the microvasculature, consumption of coagulation factors, and endogenous generation of thrombin and plasma.

In caring for the child with esophageal atresia, the nurse recognizes the priority assessment is which?

Assessment for respiratory distress. Children with esophageal atresia have periods of respiratory distress with choking and cyanosis. This is a priority assessment as the implications include the highest risk. Excessive bleeding, cardiac status for anomolies, and feeding difficulties are not concerns in the child with esophageal atresia.

The parents of a preterm newborn being cared for in the neonatal intensive care unit (NICU. are coming to visit for the first time. The newborn is receiving mechanical ventilation and intravenous fluids and medications and is being monitored electronically by various devices. Which action by the nurse would be most appropriate? A)Suggest that the parents stay for just a few minutes to reduce their anxiety. B)Reassure them that their newborn is progressing well. C)Encourage the parents to touch their preterm newborn. D)Discuss the care they will be giving the newborn upon discharge.

C)Encourage the parents to touch their preterm newborn.

The nurse is preparing discharge instructions for the parents of a male newborn who is to be circumcised before discharge. Which instruction should the nurse prioritize? Cover the glans generously with petroleum jelly. Notify the primary care provider if it appears red and sore. Cleanse the glans daily with alcohol. Soak the penis daily in warm water.

Cover the glans generously with petroleum jelly. Covering the surgical site with an ointment such as petroleum jelly prevents it from adhering to the diaper and being continually irritated. Normal appearance is red and raw. Soaking the penis daily in warm water is not recommended. Washing the penis with warm water, dribbled gently from a washcloth at each diaper change, is the recommended way of keeping the penis clean. The nurse would not tell the parents to use alcohol on the glans.

The nurse is teaching a group of students about the differences between a full-term newborn and a preterm newborn. The nurse determines that the teaching is effective when the students state that the preterm newborn has: A)Fewer visible blood vessels through the skin B)More subcutaneous fat in the neck and abdomen C)Well-developed flexor muscles in the extremities D)Greater surface area in proportion to weight

D)Greater surface area in proportion to weight

The nurse is talking with the parents of a child who has been identified as having a learning disability. The parents state that there child performs well on oral examinations but struggles otherwise on exams. The nurse is aware that the parents are describing which disorder?

Dyslexia Children with dyslexia have difficulty with reading, writing, and spelling. Children with dyscalculia have problems with mathematics and computation. Children with dyspraxia have problems with manual dexterity and coordination. Children with dysgraphia have difficulty producing the written word.

A new mother calls her pediatrician's office concerned about her 2-week-old infant "crying all the time." When the nurse explores further, the mother reports that the infant cries at least 2 hours each day, usually in the afternoons. What recommendations would the nurse not make to this mother? Swaddling the infant before returning to the crib Rocking and talking to the infant Gently patting or stroking the infant's back Feeding the infant more formula whenever she begins to fuss

Feeding the infant more formula whenever she begins to fuss Crying by a young infant is frustrating for parents, so it is suggested that the parents first be sure that the infant's physical needs are met, then soothing measures are implemented. Feeding the infant every time he cries is not needed nor suggested. Swaddling, a soothing touch and gentle pats on the back all help calm a fussy infant.

Parents are taking home their second child. They also hve a 2-year-old at home. The nurse would anticipate which behavior by these parents? General questions about different aspects of newborn care Only questions specific to breast-feeding No questions of the nurse Confidence since they have another child already

General questions about different aspects of newborn care Just because parents have had a previous child does not mean that they will not have questions about their newborn infant. Each newborn is different and parents my not feel comfortable this time caring for the newborn.

A nurse is changing a newborn's diaper and realizes that the bassinet is out of diapers. What would be the best choice of action to alleviate the problem? Go get another pack of diapers for the bassinet from the supply closet. Go to the next bassinet and take a diaper from that newborn's drawer. Tell the parents that their newborn needs more diapers. Go from bed to bed and locate some more diapers for the infant.

Go get another pack of diapers for the bassinet from the supply closet. Infection control measures dictate that there is no sharing of supplies between newborns, so the best choice would be to get another package of diapers for the newborn. Also, the parents are not responsible for diapers until after the newborn is discharged.

The nurse knows that the heads of infants and toddlers are large in proportion to their bodies, placing them at risk for what problem?

Head trauma A larger head size in relation to the rest of their body size gives young children a higher center of gravity, which causes them to hit their head more readily, thus placing them at risk for head trauma. Fragile capillaries in the periventricular area of the brain put preterm infants at risk for intracranial hemorrhage. Congenital hydrocephalus may be caused by abnormal intrauterine development or infection. Positional plagiocephaly is caused by an infant's head remaining in the same position for too long.

At a preconception counseling class, a client expresses concern and wonders how Healthy People 2020 will improve maternal infant outcomes. Which responses by the nurse are appropriate? Select all that apply.

Healthy People 2020 will reduce the rate of fetal and infant deaths. Healthy People 2020 will decrease the number of all infant deaths (within 1 year). Healthy People 2020 will decrease the number of neonatal deaths (within the first year). Healthy People 2020 will foster early and consistent prenatal care. One of the leading health indicators as identified by Healthy People 2020 refers to decreasing the number of infant deaths. Acquired and congenital conditions account for a significant percentage of infant deaths.

A ventilated 33 weeks' gestation newborn in the neonatal intensive care unit (NICU) receives surfactant therapy. Which would the nurse expect to assess as a positive response to this therapy?

Oxygen saturation levels are at 98%. Rescue treatment is indicated for newborns with established RDS who require mechanical ventilation and supplemental oxygen. The earlier the surfactant is administered, the better the effect on gas exchange with an aim to have the O2 saturation level of 98%. Glucose level assessment does not correlate with this therapy. The HR of 60 bpm is an abnormal finding and not a positive result of the therapy. The PaCO2 indicates respiratory acidosis

Which sign is consistent with autism spectrum disorder (ASD) in a 2-year-old boy?

Performs repetitive activity with toys The repetitive behavior pattern with the toys, along with observation of communication and social impairment, would suggest ASD. Below-average intellectual function is a sign of intellectual disability. Loss of attained skills is a sign of Rett syndrome, which occurs only in girls. The presence of excellent language skills suggests Asperger syndrome.

Under which circumstances should gloves be worn in the newborn nursery? Select all that apply. Providing the first bath Taking the newborn's crib to the mother's room Feeding the newborn a bottle Performing a heel stick Accucheck Changing a diaper

Providing the first bath Performing a heel stick Accucheck Changing a diaper Universal precautions, such as wearing gloves, is necessary whenever the nurse is likely to come in contact with bodily fluids, such as when changing a diaper, performing the initial bath after birth, and drawing blood for testing. Gloves are not needed with formula feedings or when transporting the newborn in its crib to the mother's room.

An infant has just been born with a cleft lip and palate. The birthing room suddenly becomes very quiet, and the birth team seem somber. The health care provider is busy examining the newborn, but the mother is obviously aware that something is not right. What should the nurse do?

Say to the parents, "Your son has been born with a cleft lip and palate. This condition is highly treatable by surgery, however, and he is otherwise in excellent health." Nurses need to be familiar with the most frequently encountered physical or developmental anomalies which are present at birth so, as the person who at that moment in the birth process is most available for client education, they can explain the problem to parents. It is a good rule to explain to parents what the disorder consists of and what the usual prognosis is before showing the baby to them as parents may find it hard to look at an infant with a cleft lip or palate or exposed abdominal contents, for example, and listen at the same time.

A nurse is caring for a newborn with jaundice undergoing phototherapy. What intervention is appropriate when caring for the newborn?

Shield the newborn's eyes The nurse should shield the newborn's eyes and cover the genitals to protect these areas from becoming irritated or burned when using direct lights and to ensure exposure of the greatest surface area. The nurse should place the newborn under the lights or on the fiberoptic blanket, exposing as much skin as possible. Breast or bottle feedings should be encouraged every 2 to 3 hours. Loose, green, and frequent stools indicate the presence of unconjugated bilirubin in the feces. This is normal; therefore, there is no need for therapy to be discontinued. Lack of frequent green stools is a cause for concern.

A nurse is assigned to care for a newborn with hyperbilirubinemia. The newborn is relatively large in size and shows signs of listlessness. What most likely occurred?

The infant's mother probably had diabetes. The nurse should know that the infant's mother more than likely was a diabetic. The large size of the infant born to a diabetic mother is secondary to exposure to high levels of maternal glucose crossing the placenta into the fetal circulation. Common problems among infants of diabetic mothers include macrosomia, respiratory distress syndrome, birth trauma, hypoglycemia, hypocalcemia and hypomagnesemia, polycythemia, hyperbilirubinemia, and congenital anomalies. Listlessness is also a common symptom noted in these infants. Infants born to clients who have abused alcohol, infants who have experienced birth traumas, or infants whose mothers have had long labors are not known to exhibit these particular characteristics, although these conditions do not produce very positive pregnancy outcomes. Infants with fetal alcohol syndrome or alcohol exposure during pregnancy do not usually have hypoglycemia problems.

Which statement is false regarding bathing the newborn? Bathing should not be done until the newborn is thermally stable. Mild soap should be used on the body and hair but not on the face. To reduce the risk of heat loss, the bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth. While bathing the newborn, the nurse should wear gloves.

To reduce the risk of heat loss, the bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth. Bathing the newborn is not necessary for thermal stability. It can be postponed until the parents are able to do it.

The nurse is caring for an 8-year-old girl who was in a car accident. Which symptom suggests the child has a cerebral contusion?

Trouble focusing when reading Signs and symptoms for cerebral contusions include disturbances to vision, strength, and sensation. A child suffering a concussion will be distracted and unable to concentrate. Vomiting is a sign of a subdural hematoma. Bleeding from the ear is a sign of a basilar skull fracture.

To feed lunch to a child with autism spectrum disorder (ASD), which action would it be most important for the nurse to take?

Use a repetitive series of movements. Children with ASD typically enjoy repetitive movements or the same action over and over.

The nurse is observing a group of 2- and 3-year-olds in a play group. Which behavior noted in one of the children indicates to the nurse that the child may have autism spectrum disorder (ASD)?

While the other children are eating a snack, the child walks around the room feeling the walls and ignores the caregiver who offers him a snack. Children with ASD become completely absorbed in strange repetitive behaviors such as spinning an object, flipping an electrical switch on and off, or walking around the room feeling the walls. If these movements are interrupted or if objects in the environment are moved, a violent temper tantrum may result. These tantrums may include self-destructive acts such as hand biting and head banging. Although infants and toddlers normally are self-centered, ritualistic, and prone to displays of temper, autistic children show these characteristics to an extreme degree coupled with an almost total lack of response to other people

The nurse is admitting a 10-pound (4.5-kg) newborn to the nursery. What is important for the nurse to monitor during the transition period? Apgar score heart rate blood sugar temperature

blood sugar Most facilities have protocols to guide nursing care in the treatment of hypoglycemia. Many pediatricians have preprinted orders that can be initiated if the glucose level falls below a predetermined level (usually 40-50 mg/dL).

The nurse is caring for an infant who has undergone surgery for infantile glaucoma. What is the priority nursing intervention? a. Place the child prone postoperatively for comfort. b. Teach the family use of the contact lens. c. Place elbow restraints on the infant. d. Provide a mobile for optical stimulation.

c. It is very important to protect the operative site after any eye surgery. Elbow restraints prevent the infant from rubbing the eyes.

The nurse is assessing a newborn suspected of having meconium aspiration syndrome. What sign or symptom would be most suggestive of this condition?

expiratory grunting Expiratory grunting, a barrel-shaped chest with an increased anterior-posterior chest diameter, prolonged tachypnea, progression from mild-to-severe respiratory distress, intercostal retractions, cyanosis, surfactant dysfunction, airway obstruction, hypoxia, and chemical pneumonitis with inflammation of pulmonary tissues are seen in a newborn with meconium aspiration syndrome. A high-pitched cry may be noted in periventricular hemorrhage/intraventricular hemorrhage. Bile-stained emesis occurs in necrotizing enterocolitis. Intermittent tachypnea can be indicative of transient tachypnea of the newborn or any mild respiratory distress problem.

The newborn nursery nurse suspects a newborn of having neonatal abstinence syndrome. What assessment findings would most correlate with the diagnosis?

frequent yawning and sneezing Manifestations of neonatal abstinence syndrome include: CNS dysfunction such as hyperactive reflexes resulting in exaggerated Babinski and Moro reflexes; hypertonic muscle tone and constant movement; metabolic, vasomotor, and respiratory disturbances with frequent yawning and sneezing; gastrointestinal dysfunction, including poor feeding; and frantic sucking or rooting. Acrocyanosis is a normal newborn finding which is cyanotic discoloration of the extremities.

For which condition would the nurse commonly assess in an infant following surgery for a myelomeningocele?

hydrocephalus Surgery includes removing a portion of the meninges; without the surface to absorb cerebral spinal fluid, hydrocephalus can result.

In addition to newborns of diabetic mothers being at risk for hypoglycemia, these newborns are also at risk for which condition?

hypocalcemia The newborn of the diabetic mother is at risk for hypocalcemia, hypomagnesemia, polycythemia with hyperviscosity, and hyperbilirubinemia. Potassium concerns are not a risk for these newborns.

The nurse would identify for a new mother which of the following as the greatest benefit of breastfeeding? a) decreased expense b) convenience c) immunity against many different bacteria d) better taste

immunity against many different bacteria Correct Explanation: Human breast milk provides a passive mechanism to protect the newborn against the dangers of a deficient intestinal defense system. It contains antibodies, leukocytes, and many other substances that can interfere with bacterial colonization and prevent harmful penetration. Convenience and being less expensive are also benefits, but not the most important one. Tasting better is an individual preference: some babies will take only breast milk, while others prefer formula.

A newborn is diagnosed with respiratory distress syndrome (RDS). While assessing the newborn, the nurse realizes that which maternal factor would most place the infant at risk for RDS?

maternal gestational diabetes Prolonged rupture of membranes, gestational or chronic maternal hypertension, maternal narcotic addiction, and the use of prenatal corticosteroids reduces the newborn's risk for RDS because of the physiologic stress imposed on the fetus. Chronic stress experienced by the fetus in utero accelerates the production of surfactant before 35 weeks' gestation and thus reduces the incidence of RDS at birth. Maternal diabetes produces high levels of insulin that inhibits surfactant production thus placing the newborn more at risk for developing RDS.

When planning preoperative care for a newborn with a cleft lip and palate, a major need for which the nurse would plan interventions is:

nutrition. An infant with a cleft lip is unable to suck effectively, so obtaining adequate nutrition is a major concern

It would be best to place an infant with a myelomeningocele in which position prior to surgery?

on the stomach (prone) Placing the infant prone prevents direct trauma to the lesion and reduces the chance that feces will contaminate the lesion.

The nurse is changing the diaper on a newborn and notices that there is a musty smell to the infant's urine. This finding is a characteristic sign of which disorder?

phenylketonuria There is a characteristic musty smell to the urine in the child with phenylketonuria. None of the other disorders affect the urine or the smell of the urine.

A 30 weeks' gestation neonate born with low Apgar scores is in the neonatal intensive care unit with respiratory distress syndrome and underwent an exchange transfusion for anemia. Which factors place the neonate at risk for necrotizing enterocolitis? Select all that apply

preterm birth respiratory distress syndrome low Apgar scores exchange transfusion The predisposing factors for the development of necrotizing enterocolitis include preterm labor, respiratory distress syndrome, exchange transfusion, and low birth weight. Low Apgar scores, hypothermia, and hypoglycemia are also risk factors.

The nurse is caring for a baby born to a mother with a history of alcohol abuse. For what characteristics should the nurse observe to determine if the newborn has fetal alcohol syndrome? Select all that apply.

reduced ocular growth short palpebral fissures flattened nasal bridge The newborn withdrawing from alcohol typically is hyperactive and irritable, has trouble sleeping, and may have tremors or seizures. Characteristics of fetal alcohol syndrome (FAS) include low birth weight, small height and head circumference, short palpebral fissures, reduced ocular growth, and a flattened nasal bridge.

A nurse is teaching new parents about keeping follow-up appointments and calling their health care provider if they notice signs of illness in their newborn. The nurse determines that the teaching was successful when the parents identify which signs as needing to be reported? Select all that apply. temperature of 38.3° C (101° F) or higher refuse feeding abdominal distention general fussiness approximately eight wet diapers a day

temperature of 38.3° C (101° F) or higher refuse feeding abdominal distention Parents should call their health care provider if they note any of the following warning signs: temperature of 38.3° C (101° F) or higher; forceful, persistent vomiting; refusal to take feedings; two or more green, watery diarrheal stools; infrequent wet diapers and change in bowel movements from normal pattern; lethargy or excessive sleepiness; inconsolable crying and extreme fussiness; abdominal distention; or difficult or labored breathing.

Which newborn would the nurse suspect to be most at risk for cognitive challenge due to the mother's actions during pregnancy?

the child of a client who admits to drinking a liter of alcohol daily during the pregnancy Fetal alcohol syndrome is one of the most common known causes of cognitive challenge. The newborn is also at risk for fetal alcohol spectrum disorder and other alcohol-related birth defects. The other illicit drugs are not linked to mental retardation but have many other teratogenic effects on the fetus/newborn. Marijuana has not shown to have teratogenic effects on the fetus.

A new student asks what "neonatal period" means. The instructor defines it as which of the following? a) the first week of life b) the first 28 days of life c) the first 72 hours of life d) the first 3 days of life

the first 28 days of life Correct Explanation: The term neonatal period is defined as the first 28 days of life.

A nurse working in the newborn observational unit is assigned four newborns closely being monitored. Which newborn is at greatest risk of developing respiratory distress syndrome?

the male preterm infant born by cesarean birth with cold stress The most common factor is a premature birth with additional factors of cesarean births and cold stress. Vaginal births and a parental history of asthma do not correlate with RDS. A positive Babinski reflex is normal in newborns and children up to 2 years old. Maternal hypertension with a term birth as well do not correlate.

The nurse caring for a newborn has to perform assessment at various intervals. When should the nurse complete the second assessment for the newborn? within the first 2 to 4 hours, when the newborn reaches the nursery prior to the newborn being discharged 24 hours after the newborn's birth within 30 minutes after birth, in the birthing area

within the first 2 to 4 hours, when the newborn reaches the nursery The nurse should complete the second assessment for the newborn within the first 2 to 4 hours, when the newborn is in the nursery. The nurse should complete the initial newborn assessment in the birthing area and the third assessment before the newborn is discharged, whenever that may be.

A 9-year-old diagnosed with neurofibromatosis is being evaluated for the presence of a brain tumor. What tests may be ordered to diagnose this condition?

• Computed tomography • Magnetic resonance imaging Computed tomography is used for visualization of tumors, ventricles, brain tissue, CSF, hematomas, and cysts. Magnetic resonance imaging is also useful in tumor identification. Lumbar puncture is used to measure CSF pressure and collect CSF samples for laboratory tests. Electroencephalograms detect and locate abnormal electrical discharges produced in the brain. Radiology identifies the presence of fractures, widened skull sutures, calcifications, bone erosion, or skeletal anomalies

A child with a seizure disorder is being admitted to the inpatient unit. When preparing the room for the child, what should be included?

• Oxygen gauge and tubing • Suction at bedside • Padding for side rails When planning the client's environment it is imperative that both safety items and those to manage the seizure are present. The side rails should be padded to prevent injury during seizure activity. Oxygen setup should be provided. Suction may be needed. Tongue blades and smelling salts are not employed.

An 11-year-old child was recently diagnosed with chickenpox. His parents gave him aspirin for a fever and the child is now hospitalized. Which nursing interventions are appropriate for this child?

• Request order for an antiemetic • Assess intake and output every shift • Request order for anticonvulsant This child likely has Reye syndrome and may require an anti-emetic for severe vomiting. The nurse should monitor the child's intake and output every shift for the development of fluid imbalance. The child may require an anticonvulsant due an increased intracranial pressure that may induce seizures. A distinctive rash is associated with the development of meningococcal meningitis. The nurse should monitor the Reye's syndrome child's laboratory values for indications that the liver is not functioning well

A 10-year-old girl with ADHD has been on Ritalin (methylphenidate) for 6 months. The girl's mother calls and tells the nurse that the medication is ineffective and requests an immediate increase in the child's dosage. What should the nurse say?

"Let's set up an appointment as soon as possible." The nurse plays a vital role in administering medicines and observing and reporting responses. A face-to-face appointment with the family and the doctor or advance practice mental health nurse can help uncover client and parental factors that may be preventing success. Once it is established that the family is using the medication properly as well as instituting structure within the home, it can be determined if an increased dosage or alternate medicine would be appropriate. Deferring to the doctor will not elicit any information from the mother, and waiting will not address the current concerns. The teacher can only reveal partial information about the effectiveness of the medication, which can be reviewed once other factors have been addressed in a face-to-face visit with the family and client.

17. Chelation therapy is begun on a child with b-thalassemia major. The purpose of this therapy is to: a. treat the disease. b. eliminate excess iron. c. decrease risk of hypoxia. d. manage nausea and vomiting.

ANS: B A complication of the frequent blood transfusions in thalassemia is iron overload. Chelation therapy with deferoxamine (an iron-chelating agent) is given with oral supplements of vitamin C to increase iron excretion. Chelation therapy treats the side effect of the disease management. Decreasing the risk of hypoxia and managing nausea and vomiting are not the purposes of chelation therapy.

MULTIPLE CHOICE 1. Which child should the nurse document as being anemic? a. 7-year-old child with a hemoglobin of 11.5 g/dl b. 3-year-old child with a hemoglobin of 12 g/dl c. 14-year-old child with a hemoglobin of 10 g/dl d. 1-year-old child with a hemoglobin of 13 g/dl

ANS: C Anemia is a condition in which the number of red blood cells, or hemoglobin concentration, is reduced below the normal values for age. Anemia is defined as a hemoglobin level below 10 or 11 g/dl. The child with a hemoglobin of 10 g/dl would be considered anemic. The normal hemoglobin for a child after 2 years of age is 11.5 to 15.5 g/dl.

34. Which is a common clinical manifestation of Hodgkin disease? a. Petechiae b. Bone and joint pain c. Painful, enlarged lymph nodes d. Enlarged, firm, nontender lymph nodes

ANS: D Asymptomatic, enlarged, cervical or supraclavicular lymphadenopathy is the most common presentation of Hodgkin disease. Petechiae are usually associated with leukemia. Bone and joint pain are not likely in Hodgkin disease. The enlarged nodes are rarely painful.

42. An 8-year-old girl is receiving a blood transfusion when the nurse notes that she has developed precordial pain, dyspnea, distended neck veins, slight cyanosis, and a dry cough. These manifestations are most suggestive of: a. air emboli. b. allergic reaction. c. hemolytic reaction. d. circulatory overload.

ANS: D The signs of circulatory overload include distended neck veins, hypertension, crackles, dry cough, cyanosis, and precordial pain. Signs of air embolism are sudden difficulty breathing, sharp pain in the chest, and apprehension. Allergic reactions are manifested by urticaria, pruritus, flushing, asthmatic wheezing, and laryngeal edema. Hemolytic reactions are characterized by chills, shaking, fever, pain at infusion site, nausea, vomiting, tightness in chest, flank pain, red or black urine, and progressive signs of shock and renal failure.

28. Which immunization should not be given to a child receiving chemotherapy for cancer? a. Tetanus vaccine b. Inactivated poliovirus vaccine c. Diphtheria, pertussis, tetanus (DPT) d. Measles, rubella, mumps

ANS: D The vaccine used for measles, mumps, and rubella is a live virus and can result in an overwhelming infection. Tetanus vaccine, inactivated poliovirus vaccine, and diphtheria, pertussis, tetanus (DPT) are not live virus vaccines.

What is the best way for the nurse to assess the newborn's heartbeat? a) Palpating the femoral pulse for 30 seconds and multiplying by 2 b) Palpating the brachial pulse for 60 seconds c) Auscultating the apical pulse for 30 seconds and multiplying by 2 d) Auscultating the apical pulse for 60 seconds

Auscultating the apical pulse for 60 seconds Correct Explanation: The best way for the nurse to assess the newborn's heart rate is to listen at the apical pulse for a full minute.

A breastfeeding mother wants to know how to help her 2-week-old newborn gain the weight lost after birth. Which action should the nurse suggest as the best method to accomplish this goal? Weigh the infant daily to ensure that she is gaining 1.5 to 2 ounces (42.5 to 57 grams) per day. Recommend that the mother pump her breast milk and measure it before feeding. Add cereal to the newborn's feedings twice a day. Breastfeed the infant every 2 to 4 hours on demand.

Breastfeed the infant every 2 to 4 hours on demand. Breastfeeding the newborn every 2 to 4 hours on demand is the best way to help the infant gain weight the fastest. Normal weight gain for this age infant is .66 to 1 ounce (19 to 28 grams) per day, not 1.5 to 2 ounces (42.5 to 57 grams). Cereal is never given to infants this young. The mother does not need to pump her breast milk to measure it. As long as the newborn is feeding well and has 6+ wet diapers and 3+ stools, the infant is receiving adequate nutrition.

What finding is consistent with increased ICP in the child?

Bulging fontanel Children with increased ICP exhibit bulging fontanels. They typically have a decreased appetite, are restless, and have trouble sleeping.

A child is diagnosed with bacterial meningitis. The nurse would suspect which abnormality of cerebrospinal fluid (CSF)?

Cloudy appearance In the CSF of clients diagnosed with bacterial meningitis, the pressure is elevated, the appearance is cloudy, and the leukocytes are elevated. A decreased sugar content is noted.

A 7-year-old child is diagnosed with a learning disability involving reading, writing, and spelling. The nurse identifies this as:

Dyslexia. Dyslexia is a learning disability that involves reading, writing, and spelling. Dyscalculia is a learning disability that involves mathematics and computation. Dyspraxia is a learning disability that involves problems with manual dexterity and coordination. Dysgraphia is a learning disability that involves problems producing the written word.

The nurse is inspecting the mouth of a newborn and finds small, white cysts on the gums and hard palate. The nurse documents this finding as: thrush. milia. vernix caseosa. Epstein's pearls.

Epstein's pearls. Epstein's pearls are small, white epidermal cysts on the gums and hard palate that disappear in weeks. Thrush is white plaque inside the mouth caused by exposure to Candida albicans during birth, which cannot be wiped away with a cotton-tipped applicator. Milia are multiple pearly-white or pale yellow unopened sebaceous glands frequently found on a newborn's nose. Vernix caseosa is a thick white substance that protects the skin of the fetus. It is formed by secretions from the fetus's oil glands and is found during the first 2 or 3 days after birth in body creases and the hair.

The nurse caring for a child with a cranial injury knows that broad-spectrum antibiotics are used to reduce cerebral edema.

False Antibiotics or antivirals are used to treat infectious disease processes. Glucocorticoids and diuretics are used to reduce cerebral edema.

The nurse is preparing the nursing care plan for a newborn who was born via a cesarean delivery. Which diagnosis should the nurse prioritize? Ineffective airway clearance related to mucus and secretions Altered nutrition less than body requirement related to limited formula intake Altered urinary elimination related to postcircumcision status Ineffective thermoregulation related to heat loss to the environment

Ineffective airway clearance related to mucus and secretions Any airway clearance or obstruction issue is the highest priority for nursing interventions, whether the infant is born via vaginal or cesarean delivery. The other options are valid nursing diagnoses for some newborns; however, they would not take precedence over an airway problem.

Infants have a substance in their lungs, surfactant. What is role of surfactant in the respiratory system? a) Removes fluid from the lungs b) Keeps alveoli from collapsing with breaths c) Allows oxygen to move in the lungs d) Expands the lungs with breaths

Keeps alveoli from collapsing with breaths Correct Explanation: The role of surfactant is to act on surface tension and assist to keep the alveoli open in the lungs so the lungs do not collapse with the respiratory effort of the newborn. Surfactant does not expand the lungs, remove fluid from the lungs, nor allow oxygen to move in the lungs.

The parents of a 2-day-old newborn are preparing for discharge from the hospital. They question the nurse concerning sleeping patterns for the newborn once they get home. What advice can the nurse provide for them? Place the infant on his abdomen or side to encourage sleep. If the infant continues to wake up at night after a few months, offer rice cereal before going to bed. Expect the infant to sleep through the night by 2 months of age. Newborns usually sleep for 16 or more hours each day, broken into periods of 3 to 4 hours per session.

Newborns usually sleep for 16 or more hours each day, broken into periods of 3 to 4 hours per session. Normally, newborns sleep 16 to 20 hours per day. Timing for sleeping through the night varies from infant to infant and should not be predicted to parents. Infants are always placed on their backs to sleep to reduce the risk of SIDS. Giving an infant solids earlier than 6 months is not helpful in encouraging them to sleep through the night and may upset their digestive tract.

A nurse is caring for a newborn with anencephaly. Which intervention will the nurse use?

Place a cap or similar covering on the infant's head. Using an infant cap can help parents deal with the malformed appearance of their child. Because the child was born with a small or missing brain, the baby will likely die within hours or days. Monitoring for increased intracranial pressure (ICP) or neurologic status are not necessary interventions.

Rumination disorder is a poorly understood condition of young children. This refers to:

Rechewing undigested food. Rumination is the rechewing of undigested food. It occurs primarily in infants

The nurse is preparing a care plan for a child who has a seizure disorder. The child experiences tonic-clonic seizures. Which nursing diagnosis will the nurse identify as having the highest priority?

Risk for injury A seizure disorder is caused by a disruption in the electrical impulses in the brain. Tonic-clonic seizures is the most dramatic seizure disorder. It is characterized by a loss of consciousness, along with the entire body experiencing tonic contractions followed by rhythmic clonic contractions alternating with relaxation of all muscle groups. Cyanosis may be noted due to apnea, and saliva may collect in the mouth due to inability to swallow. All of these symptoms would make Risk for injury the highest priority.

In caring for the child with meningitis, the nurse recognizes that which nursing diagnosis would be the most important to include in this child's plan of care?

Risk for injury related to seizure activity The child's risk for injury would be an appropriate nursing diagnosis. Surgery is not indicated for the child with meningitis, and the history of seizures does not impact the airway clearance. Growth and development issues are a concern but not likely delayed due to this diagnosis.

Steve, a 15-year-old Vietnamese boy, has been referred by his homeroom teacher to the school nurse for evaluation. The teacher is concerned that Steve may be suffering from major depression. Who should be the primary source of information to investigate the concerns about Steve?

Steve Steve is the primary historian, and the nurse should first elicit his perspective on the problem to establish a therapeutic alliance. The school nurse might have some input, but his or her contact with Steve may have been minimal. Steve's parents can provide insight and assistance, but they may not be willing to do so because of cultural differences. The teacher will provide a valuable timeline and observations as the individual who referred this case; however, Steve is still the primary historian.

A mother tells the nurse that she has been reading a book that says that newborns need stimulation to develop properly and asks what she can do to help her infant. Which tip would not be helpful to the mother? Rocking and singing to her infant. Swaddling the infant Holding and cuddling the infant Use of mobiles above the crib.

Swaddling the infant Stimulation of an infant allows the infant to experience the 5 senses. Holding and cuddling the infant addresses the sense of touch. Singing to the infant provides auditory stimulation. A mobile above the crib provides visual stimulation. Swaddling the infant may be comforting but provides no stimulation for the infant.

When assessing the newborn's umbilical cord, what should the nurse expect to find? a) One smaller artery and two larger veins b) Two smaller veins and one larger artery c) One smaller vein and two larger arteries d) Two smaller arteries and one larger vein

Two smaller arteries and one larger vein Explanation: When inspecting the vessels in the umbilical cord, the nurse should expect to encounter one larger vein and two smaller arteries. In 0.5% of births (3.5% of twin births), there is only one umbilical artery, which can be linked to cardiac or chromosomal abnormalities.

As the nurse examines the birth records, which newborn would the nurse expect to monitor closely for respiratory distress syndrome (RDS)?

a term male newborn, born by a repeat cesarean birth, whose mother has diabetes mellitus It is necessary to review the maternal history for risk factors associated with RDS. Risk factors in the term infant placing the infant at most risk include a cesarean birth in the absence of preceding labor, male gender, and maternal diabetes, which produces high levels of insulin which inhibit surfactant production. The other infant situations would not be the priority.

A newborn with high serum bilirubin is receiving phototherapy. Which nursing intervention is the most appropriate for this client?

application of eye dressings to the infant Continuous exposure to bright lights by phototherapy may be harmful to a newborn's retina, so the infant's eyes must always be covered while under bilirubin lights. Eye dressings or cotton balls can be firmly secured in place by an infant mask. The lights are placed 12 to 30 inches above the newborn's bassinet or incubator. Bilirubin is removed from the body by being incorporated into feces. Therefore, the sooner bowel elimination begins, the sooner bilirubin removal begins. Early feeding (either breast milk or formula), therefore, stimulates bowel peristalsis and helps to accomplish this. Gently shaking the infant is a method of stimulating breathing in an infant experiencing apnea.

The nurse suspects a preterm newborn receiving enteral feedings of having necrotizing enterocolitis (NEC). What assessment finding best correlates with this diagnosis?

bloody stools NEC assessment includes assessing the newborn's health history and physical examination as well as laboratory and diagnostic testing. The onset of NEC is demonstrated by the development of feeding intolerance, abdominal distention, and bloody stools in a preterm infant receiving enteral feedings. As the disease worsens, the infant develops signs and symptoms of septic shock with RDS, temperature instability, lethargy, hypotension, and oliguria.

A nurse teaches new parents that the best way to help prevent infections in the newborn is which of the following? a) breastfeed b) keep them inside for the first month of life c) keep them warm at all times d) limit visitors

breastfeed Correct Explanation: A major source of IgA, which helps in immunity, is human breast milk. Thus, breastfeeding is believed to have significant immunological advantages over formula. The other options such as keeping them in for a month and keeping them warm will not help prevent infections. Keeping the child away from people who have an infection might stop them from getting that infection. Doing so will not help build up the infant's immunity

While examining a newborn, a nurse observes salmon patches on the nape of the neck and on the eyelids. Which is the most likely cause of these skin abnormalities? an immature autoregulation of blood flow concentration of immature blood vessels bruising from the birth process an allergic reaction to the soap used for the first bath

concentration of immature blood vessels A concentration of immature blood vessels causes salmon patches. Bruising does not look like salmon patches but would be more bluish-purple in appearance. Harlequin sign is a result of immature autoregulation of blood flow and is commonly seen in low birth weight newborns. An allergic reaction would be more generalized and would not be salmon colored.

The mother of a formula-fed newborn asks how she will know if her newborn is receiving enough formula during feedings. Which response by the nurse is correct? "Your newborn should be taking about 2 oz of formula for every pound of body weight during each feeding." "A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight." "Your newborn should finish a bottle in less than 15 minutes." "If your newborn is wetting three to four diapers and producing several stools a day, enough formula is likely being consumed."

"A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight." A sign of adequate formula intake is when the newborn seems satisfied and is gaining weight regularly. The formula fed newborn should take 30 minutes or less to finish a bottle, not less than 15 minutes. The newborn does normally produce several stools per day, but should wet 6 to 10 diapers rather than 3 to 4 per day. The newborn should consume approximately 2 oz of formula per pound of body weight per day, not per feeding.

A nursing instructor is teaching about newborn congenital disorders and realizes that the student needs further instruction after making which statement?

"All congenital disorders can be diagnosed at birth." All congenital disorders are not diagnosed at birth. Hydrocephalus is one such disorder that may be diagnosed at birth but also may not be diagnosed until after a few weeks or months. It is also true that congenital defects may be caused by both genetics and environmental factors.

The nurse is doing teaching with the caregivers of an infant diagnosed with hypospadias. Which statement made by the caregivers is accurate regarding hypospadias?

"Being able to most likely correct this in one stage rather than several is reassuring." Surgical repair is often accomplished in one stage and is often done as outpatient surgery. Surgical repair is desirable between the ages of 6-18 months, before body image and castration anxiety become problems. Urination is not affected, but the boy cannot void while standing in the normal male fashion. These newborns should not be circumcised because the foreskin is used in the repair.

A 6-year-old has had a viral infection for the past 5 days and is having severe vomiting, confusion, and irritability, although he is now afebrile. During the assessment, the nurse should ask the parent which question?

"Did you use any medications like aspirin for the fever?" Severe and continual vomiting, changes in mental status, lethargy, and irritability are some of the signs and symptoms of Reye syndrome, which can occur as a result of ingesting aspirin or aspirin-containing products during a viral infection. Tylenol (acetaminophen) is allowed for viral infections in the school-age child. The type of fluids consumed during the illness has nothing to do with Reye syndrome. The temperature rise would be important for a much younger child because of the chance of febrile seizures, but not in this age child.

The mother of a toddler tells the nurse during a routine well-child appointment that she is concerned because, "It seems like my son is falling and hitting his head all of the time." What is the best response by the nurse?

"Due to the size of their heads and immature neck muscles falling is common, but I will let the physician know your concerns." The head of the infant and young child is large in proportion to the body, and is the fastest-growing body part during infancy and continues to grow until the child is 5 years old. In addition, the infant's and child's neck muscles are not well developed. Both of these differences lead to an increased incidence of head injury from falls. The nurse should still let the physician know the mother's concerns in case there is another issue causing the falls.

The mother of a newborn with a caput succedaneum asks the nurse how this happened to her baby. Which response by the nurse would be most appropriate?

"During delivery, your vaginal wall put pressure on the baby's head." Caput succedaneum results from pressure from the uterus or vaginal wall during a head-first delivery. The use of forceps is associated with a cephalohematoma. Caput succedaneum is not due to the baby's head becoming blocked inside the vagina. The cause of caput succedaneum is known; it is caused by pressure from the uterus or vaginal wall during a head-first delivery.

A client who gave birth 2 hours ago expresses concern about her baby developing jaundice. Which response from the nurse would be best?

"I understand your concern because as many as 50% of babies can develop jaundice." As many as 50% of term newborns will develop physiologic jaundice. Physiologic jaundice occurs after the first 24 hours of life and is not pathologic. Pathologic jaundice will develop within the first 24 hours of life.

A patient who gave birth 2 hours ago expresses concern about her baby developing jaundice. How should the nurse respond? Choose the best response. a) "You don't need to worry about your baby developing jaundice because you are both A+." b) "I understand your concern because as many as 50% of babies can develop jaundice." c) "If you are concerned about your baby developing jaundice, don't breastfeed your baby until you get home." d) "We will monitor the baby now, and your baby will not develop jaundice after the first 24 hours of life."

"I understand your concern because as many as 50% of babies can develop jaundice." Correct Explanation: As many as 50% of term newborns will develop physiologic jaundice. Physiologic jaundice occurs after the first 24 hours of life and is not pathologic. Pathologic jaundice will develop within the first 24 hours of life.

The nurse has just admitted a 17-year-old diagnosed with bacterial meningitis. The parents of the adolescent tell the nurse, "We just don't understand how this could have happened. Our child has always been healthy and also just received a booster vaccine last year?" How should the nurse respond?

"I understand your frustration. Unfortunately immunizations are not 100% effective in preventing the infection." Showing empathy while letting the parents know that vaccines are not 100% effective is the best response. Questioning them about being sure would not be the best response unless there was reason to believe their information was not accurate. There is nothing to lead the nurse to believe that a different strain of bacteria caused the infection, or that the the child's immune system is compromised

The nursing educator has completed an educational program for new nurses on eating disorders in teenagers. Which statement by a participant would indicate a need for further education?

"If they refuse to eat, we need to sit with them and not let them leave the table until they do eat something." Withdraw attention if the child refuses to eat: secondary gain is minimized if refusal to eat is ignored rather than with continuous attention. Mutually establish a contract related to treatment to promote the child's sense of control. Provide mealtime structure, as clear limits let the child know what the expectations are. Provide continuous supervision during the meal and for 30 minutes following it so that the child cannot conceal or dispose of food or induce vomiting.

The primipara tells the nurse, "My baby jumps every time I pick her up. Is she afraid that I will drop her?" Which response by the nurse would be best? "No, it is the blink reflex. It is meant to protect the eyes." "Yes, she is afraid you will drop her." "No, it is the Moro reflex. This reflex simulates the action of warding off an attacker." "No, it is the tonic neck reflex. It signifies handedness."

"No, it is the Moro reflex. This reflex simulates the action of warding off an attacker." The Moro reflex is known as the startle reflex. A startled newborn will extend the arms and legs away from the body and to the side. Then the arms come back toward each other with the fingers spread in a "C" shape. The arms look as if the newborn is trying to embrace something. The Moro reflex should be symmetrical.

The nurse is educating parents of a male infant with Chiari type II malformation. Which statement about their child's condition is most accurate?

"Take your time feeding your baby." One of the problems associated with Chiari type II malformation is poor gag and swallowing reflexes, so the infant must be fed slowly. There is a great risk of aspiration, requiring that the child be placed in an upright position after feeding. The goal of surgery is to prevent further symptoms, rather than to relieve existing ones. Infrequent urination is a problem associated with type I malformations

A nurse is explaining to the parents the preoperative care for their infant born with bladder exstrophy. The parents ask, "What will happen to the bladder while waiting for the surgery?" What is the nurse's best response?

"The bladder will covered in a sterile plastic bag to keep it moist." In the preoperative period, the infant care is focused on protecting the exstrophied bladder and preventing infection. The infant is kept in a supine position, and the bladder is kept moist and covered with a sterile plastic bag. Change soiled diapers immediately to prevent contamination of the bladder with feces. Sponge-bathe the infant only rather than immersing him or her in water to prevent pathogens in the bath water from entering the bladder. Consult the ostomy nurse if necessary.

A child who has been having seizures is admitted to the hospital for diagnostic testing. The child has had laboratory testing and an EEG, and is scheduled for a lumbar puncture. The parents voice concern to the nurse stating, "I don't understand why our child had to have a lumbar puncture since the EEG was negative." What is the best response by the nurse?

"The lumbar puncture can help rule out any infection in fluid surrounding the brain and spinal cord as the cause of the seizures." Lumbar punctures are performed to analyze cerebrospinal fluid (CSF) to rule out meningitis or encephalitis as a cause of seizures. A normal EEG does not rule out epilepsy because seizure activity rarely occurs during the actual testing time. A 24-hour or longer EEG can help in diagnosing a seizure disorder. Just telling the parents that it needs to be done, to be patient, or it is a routine does not address the parents' concerns.

A 1-year-old has just undergone surgery to correct craniosynostosis. Which comment is the best psychosocial intervention for the parents?

"The surgery was successful. Do you have any questions?" Often what parents need most is someone to listen to their concerns. Although this is a good time for education, let the parents adjust to their baby's appearance and adapt your teaching to their questions, comments, and knowledge level.

The parents of a newborn baby boy ask the nurse about circumcising their son. They are undecided as to what to do. Which response by the nurse is best? "There are pros and cons to circumcision. Let me ask the pediatrician to come and talk to you about the procedure." "Circumcision is best in order to protect the baby from diseases like cancer." "If you do not circumcise your baby, he will always have difficulty maintaining adequate hygiene." "It is best not to circumcise your baby because the procedure is very painful."

"There are pros and cons to circumcision. Let me ask the pediatrician to come and talk to you about the procedure." If the parents decide to have their male newborn circumcised, informed consent is necessary. It is the primary care provider's responsibility to obtain informed consent, although the nurse may be responsible for witnessing the parents' signatures to a written documentation of that consent. If the parents have unanswered questions, the nurse should notify the care provider before the procedure is done.

When instructing a new mom on providing skin care to her newborn, which statement should not be included in the teaching? "Change diapers frequently." "Give the newborn sponge baths until the umbilical cord falls off." "Daily tub baths are not necessary." "Use talc powders to prevent diaper rash."

"Use talc powders to prevent diaper rash." Talc powders can be a respiratory hazard and should not be used with a newborn.

An advance practice pediatric nurse practitioner (APPNP) is conducting a mental status examination with a 6-year-old girl. Which question would be most appropriate?

"Why does your pink doll hit all the other dolls?" The nurse is trying to elicit the fantasies and feelings underlying the child's play. Asking an open-ended question is likely to reveal this information. A 6-year-old might know the name of the president but the meaning is ambiguous. The other questions would elicit "yes" or "no" answers.

The mother of a 10-year-old boy with attention deficit hyperactivity disorder (ADHD) contacts the school nurse. She is upset because her son has been made to feel different by his peers because he has to visit the nurse's office for a lunch-time dose of medication. The boy is threatening to stop taking his medication. How should the nurse respond?

"You may want to talk to your physician about an extended-release medication." The nurse should encourage the family to explore with their physician the option of one of the newer extended-release or once-daily ADHD medications. The other statements are not helpful and do not address the mother's or boy's concerns.

When can autistic behaviors first be noticed?

1 year of age Autistic behaviors may be first noticed in infancy as developmental delays or between the age of 12 and 36 months when the child regresses or loses previously acquired skills.

Neonatal screening is done before the infant leaves the hospital. Blood is drawn through a heel stick and tested for several disorders that can cause lifelong disabilities. When is the ideal time to collect this specimen? 24 hours after the newborn's first protein feeding 36 hours before the infant is discharged home with its parents When the infant is 48 hours old Just before discharge home

24 hours after the newborn's first protein feeding The laws in most states require this initial screening, which is done within 72 hours of birth. The ideal time to collect the specimen is after the newborn is 36 hours old and 24 hours after he has his first protein feeding.

How long is the neonatal period for a newborn? ____ days

28 Correct Explanation: The neonatal period is the first 28 days of life.

When caring for a newborn several hours after birth, you assess his respiratory rate. In a normal newborn, this would be a) 16 to 20 breaths/min. b) 30 to 60 breaths/min. c) 20 to 30 breaths/min. d) 12 to 16 breaths/min.

30 to 60 breaths/min. Correct Explanation: Newborns typically breathe more rapidly than adults or older children, at a rate of 30 to 60 breaths/min. 12 to 16 breaths/min is a normal respiratory rate for an adult; 16 to 20 breaths/min is normal for older children; 20 to 30 breaths/min is normal for preschoolers; and 30 to 60 breaths/min is normal for infants.

The nurse records a newborn's Apgar score at birth. A normal 1-minute Apgar score is: 5 to 9. 12 to 15. 7 to 10. 1 to 2.

7 to 10. An Apgar score of 7 to 10 implies the infant is breathing well and cardiovascular adaptation is occurring.

After teaching a class about the changes in the gastrointestinal system of a newborn, which of the following if stated by the class indicates the need for additional teaching? a) The newborn's stomach is sterile at birth b) Oral intake is required for the production of vitamin K c) A newborn's stomach capacity is approximately 300 mL d) The cardiac sphincter is immature.

A newborn's stomach capacity is approximately 300 mL. Correct Explanation: A newborn's stomach capacity is approximately 30 to 90 mL. The gut is sterile at birth but changes rapidly depending on what feeding is received. Colonization of the gut is dependent on oral intake; oral intake is required for the production of vitamin K. The cardiac sphincter and nervous control of the stomach are immature.

A 6-year-old is seen in a mental health clinic for possible hyperactivity. His mother reports that he is just "all boy." He has always been active and does not like to sit still for more than a minute. Which data would be most important to assess to help evaluate his behavior?

A review of the boy's typical day Evaluating whether children are hyperactive requires a careful history documenting attention span and activities.

A nurse is developing a plan of care for a preterm newborn to address the nursing diagnosis of risk for delayed development. Which of the following would the nurse include? (Select all that apply.) A) Clustering care to promote rest B) Positioning newborn in extension C) Using kangaroo care D) Loosely covering the newborn with blankets E) Providing nonnutritive sucking

A) Clustering care to promote rest C) Using kangaroo care E) Providing nonnutritive sucking

19. A possible cause of acquired aplastic anemia in children is: a. drugs. b. injury. c. deficient diet. d. congenital defect.

ANS: A Drugs, such as chemotherapeutic agents and several antibiotics (e.g., chloramphenicol), can cause aplastic anemia. Injury, deficient diet, and congenital defect are not causative agents in acquired aplastic anemia.

39. The school nurse is informed that a child with human immunodeficiency virus (HIV) will be attending school soon. Which is an important nursing intervention? a. Carefully follow universal precautions. b. Determine how the child became infected. c. Inform the parents of the other children. d. Reassure other children that they will not become infected.

ANS: A Universal precautions are necessary to prevent further transmission of the disease. It is not the role of the nurse to determine how the child became infected. Informing the parents of other children and reassuring children that they will not become infected is a violation of the childs right to privacy.

24. Myelosuppression, associated with chemotherapeutic agents or some malignancies such as leukemia, can cause bleeding tendencies because of a(n): a. decrease in leukocytes. b. increase in lymphocytes. c. vitamin C deficiency. d. decrease in blood platelets.

ANS: D The decrease in blood platelets secondary to the myelosuppression of chemotherapy can cause an increase in bleeding. The child and family should be alerted to avoid risk of injury. Decrease in leukocytes, increase in lymphocytes, and vitamin C deficiency would not affect bleeding tendencies.

The parents of a newborn male are questioning the nurse concerning the pros and cons of a circumcision. Which disadvantage should the nurse point out to these parents? Fewer complications than if done later in life Anesthetic may not be effective during the procedure Lower rate of urinary tract infections Reduced risk of penile cancer

Anesthetic may not be effective during the procedure The anesthetic block is not always effective when used and not all providers will even use anesthetics prior to the procedure, thus the infant can feel the pain of the circumcision. A lower rate of urinary tract infections, a reduced risk of penile cancer, and fewer complications than if circumcised later in life are advantages to the procedure.

The eyes of a 9-year-old who suffered a head injury are crossed. Besides checking ICP, which intervention would be most important for the nurse to perform?

Assess the child's level of consciousness. Decreased level of consciousness is frequently the first sign of major neurologic problems after head trauma. While body temperature is an important indicator of infection, it is not a priority here. Preventing harm by setting the side rails is more important for a seizure client. The child's eyes will correct themselves when ICP is reduced.

Which of the following, if noted in the maternal history, would the nurse identify as possibly contributing to the birth of an LGA newborn? A) Drug abuse B) Diabetes C) Preeclampsia D) Infection

B) Diabetes

The nurse is reviewing the medical record of a newborn born 2 hours ago. The nurse notes that the newborn was delivered at 35 weeks gestation. The nurse would classify this newborn as which of the following? A) Preterm B) Late preterm C) Full term D) Postterm

B) Late preterm

When describing newborns with birth-weight variations to a group of nursing students, the instructor identifies which variation if the newborn weighs 5.2 lb at any gestational age? A) Small for gestational age B) Low birth weight C) Very low birth weight D) Extremely low birth weight

B) Low birth weight

Which of the following would be most appropriate for the nurse to do when assisting parents who have experienced the loss of their preterm newborn? A) Avoid using the terms death or dying. B) Provide opportunities for them to hold the newborn. C) Refrain from initiating conversations with the parents. D) Quickly refocus the parents to a more pleasant topic.

B) Provide opportunities for them to hold the newborn.

A woman gives birth to a newborn at 36 weeks gestation. She tells the nurse, I'm so glad that my baby isn't premature. Which response by the nurse would be most appropriate? A) You are lucky to have given birth to a term newborn. B) We still need to monitor him closely for problems. C) How do you feel about delivering your baby at 36 weeks? D) Your baby is premature and needs monitoring in the NICU.

B) We still need to monitor him closely for problems.

A child has been diagnosed with a basilar skull fracture. The nurse identifies ecchymosis behind the child's ear. This would be documented as:

Battle sign. Two signs of basilar skull fracture include Battle sign (bruising or ecchymosis behind the ear) and "raccoon eyes" (blood leaking into the frontal sinuses causing an edematous and bruised periorbital area). Rhinorrhea is CSF leakage from the nose. Otorrhea is CSF leaking from the ear.

What is the primary mechanism for temperature regulation in a newborn infant? a) Brown fat store usage b) Shivering and increased metabolic rate c) External with blankets by the nursing staff d) Skin to skin contact with mother

Brown fat store usage Explanation: Brown fat stores are the stores used by the newborn infant to maintain warmth until feeding begins and the infant is able to maintain temperature without assistance. The infant's thermoregulatory system is not fully functional at birth. Infants cannot shiver to warm themselves. The use of external blankets as well as skin to skin contact with the mother assist in keeping the baby's temperature within the normal range, but they are not the primary mechanism for temperature regulation in the newborn infant.

A nurse is developing a plan of care for a preterm infant experiencing respiratory distress. Which of the following would the nurse be least likely to include in this plan? A) Stimulate the infant with frequent handling. B) Keep the newborn in a warmed isolette. C) Administer oxygen using a oxygen hood. D) Give gavage or continous tube feedings.

C) Administer oxygen using a oxygen hood.

The nurse is assessing a preterm newborns fluid and hydration status. Which of the following would alert the nurse to possible overhydration? A) Decreased urine output B) Tachypnea C) Bulging fontanels D) Elevated temperature

C) Bulging fontanels

A group of nursing students are reviewing the literature in preparation for a class presentation on newborn pain prevention and management. Which of the following would the students be most likely to find about this topic? A) Newborn pain is frequently recognized and treated B) Newborns rarely experience pain with procedures C) Pain is frequently mistaken for irritability or agitation D) Newborns may be less sensitive to pain than adult.

C) Pain is frequently mistaken for irritability or agitation

A group of pregnant women are discussing high-risk newborn conditions as part of a prenatal class. When describing the complications that can occur in these newborns to the group, which would the nurse include as being at lowest risk? A)Small-for-gestational-age (SGA. newborns B)Large-for-gestational-age (LGA. newborns C)Appropriate-for-gestational-age (AGA. newborns D)Low-birth-weight newborns

C)Appropriate-for-gestational-age (AGA. newborns)

The nurse frequently assesses the respiratory status of a preterm newborn based on the understanding that the newborn is at increased risk for respiratory distress syndrome because of which of the following? A)Inability to clear fluids B)Immature respiratory control center C)Deficiency of surfactant D)Smaller respiratory passages

C)Deficiency of surfactant

When assessing a postterm newborn, which of the following would the nurse correlate with this gestational age variation? A)Moist, supple, plum skin appearance B)Abundant lanugo and vernix C)Thin umbilical cord D)Absence of sole creases

C)Thin umbilical cord

The nurse is caring for a girl with anorexia who has been hospitalized with unstable vital signs and food refusal. The girl requires enteral nutrition. The nurse is alert for which complications that signal refeeding syndrome?

Cardiac arrhythmias, confusion, seizures The nurse should be aware that rapid nutritional replacement in the severely malnourished can lead to refeeding syndrome. Refeeding syndrome is characterized by cardiovascular, hematologic, and neurologic complications such as cardiac arrhythmias, confusion, and seizures. Orthostatic hypotension, hypertension, and irregular and decreased pulses are complications of anorexia but do not characterize refeeding syndrome.

What is the term for a small collection of blood that forms underneath the skull as a result of birth trauma? a) Caput succedaneum b) Vernix caseosa c) Erythema toxicum d) Cephalhematoma

Cephalhematoma Correct Explanation: Vernix caseosa is a thick white substance found on a newborn. Erythema toxicum is a newborn rash. Caput succedaneum is molding or edema.

Eliminating drafts in the delivery room and in the nursery will help to prevent heat loss in a newborn through which mechanism? a) Conduction b) Convection c) Evaporation d) Radiation

Convection Correct Explanation: Convection refers to loss of heat from the newborn's body to the cooler surrounding air.

All of the following are signs of respiratory distress in the newborn EXCEPT a) Central cyanosis b) Chest retractions c) Coughing and a respiratory rate above 50 d) Grunting e) Nasal flaring

Coughing and a respiratory rate above 50 Correct Explanation: Coughing and sneezing are normal reflexes present in newborns. The expected respiratory rate of newborn is 30 to 60 breaths per minute.

The therapy you would expect to see prescribed for an adolescent with anorexia nervosa would be:

Counseling to improve feelings of control over her body. Adolescents with eating disorders need to increase self-esteem or a feeling that they have control over their life.

A nurse is assisting the anxious parents of a preterm newborn to cope with the situation. Which statement by the nurse would be least appropriate? A) I'll be here to help you all along the way. B) What has helped you to deal with stressful situations in the past? C) Let me tell you about what you will see when you visit your baby. D) Forget about whats happened in the past and focus on the now.

D) Forget about whats happened in the past and focus on the now.

When performing newborn resuscitation, which action would the nurse do first? A) Intubate with an appropriate-sized endotracheal tube. B) Give chest compressions at a rate of 80 times per minute. C) Administer epinephrine intravenously. D) Suction the mouth and then the nose.

D) Suction the mouth and then the nose.

Which of the following would alert the nurse to suspect that a preterm newborn is in pain? A) Bradycardia B) Oxygen saturation level of 94% C) Decreased muscle tone D) Sudden high-pitched cry

D) Sudden high-pitched cry

A preschool-age child has just been admitted to the pediatric unit with a diagnosis of bacterial meningitis. The nurse would include which recommendation in the nursing plan?

Decrease environmental stimulation A child with the diagnosis of meningitis is much more comfortable with decreased environmental stimuli. Noise and bright lights stimulate the child and can be irritating, causing the child to cry, in turn increasing intracranial pressure. Vital signs would be taken initially every hour and temperature monitored every 2 hours. Children with bacterial meningitis are usually much more comfortable if allowed to lie flat because this position doesn't cause increased meningeal irritation.

You are the oncoming nursery nurse caring for a 3-hour-old newborn boy. You make your initial assessment and find the following: Respiratory rate 30 bpm, B/P 60/40 mm/Hg, heart rate 155, temperature (Axillary) 36.8 °C. You assess that the newborn is in a state of quiet alert. What would you do? a) Stimulate the newborn b) Inform the charge nurse c) Call the physician d) Document the data

Document the data Correct Explanation: The normal respiratory rate is 30 to 60 breaths per minute and should be counted for a full minute when the infant is quiet. A newborn starts with a low blood pressure (60/40 mm/Hg) and a high pulse (120 to 160 bpm). Normal temperature range is between 97.7 °F (36.5 °C) and 99.5 °F (37.5 °C).

The nurse and an adolescent are reviewing the adolescent's record of her headaches and activities surrounding them. What activity would the nurse identify as a possible trigger?

Drinking three cans of diet cola Cola contains caffeine, which is an associated trigger. Intense activity, not regular exercise, may be a trigger. Odors, such as strong perfumes, may be a trigger. Changes in sleeping patterns may be a trigger.

What are small unopened or plugged sebaceous glands that occur in a newborn's mouth and gums? milia stork bites Epstein's pearls Mongolian spots

Epstein's pearls Unopened sebaceous glands are generally called milia. When they are in the mouth and gums, they are called Epstein's pearls.

The newborn has been placed in skin-to-skin contact with his mother. A blanket covers all of his body except his head. His hair is still wet with amniotic fluid, etc. What is the most likely type of heat loss this baby may experience? Evaporative Conductive Convective Radiating

Evaporative Evaporative heat loss occurs with the evaporation of fluid from the infant.

The nurse is preparing a plan to educate the parents of a 10-year-old boy with a learning disorder. What will be part of this plan?

Explain the child's strengths and weaknesses. The nurse will explain the nature of the child's disorder but will also point out the strengths the child possesses as part of the plan. Encouraging parents to provide a personal space for the child is an intervention meant to promote autonomy and responsibility for a child with delayed growth and development. Regularly checking up on the child is a preventive measure to promote safety for a child with a developmental disorder. Learning facial expressions is important when a child has impaired communication skills.

The mother of a newborn observes a diaper rash on her newborn's skin. Which intervention should the nurse instruct the parent to implement to treat the diaper rash? Place the newborn's buttocks in warm water after each void or stool. Expose the newborn's bottom to air several times a day. Use products such as talcum powder with each diaper change. Use only baby wipes to cleanse the perianal area.

Expose the newborn's bottom to air several times a day. The nurse should instruct the parent to expose the newborn's bottom to air several times per day to treat and prevent diaper rashes. Use of baby wipes and products such as powder should be avoided. The parent should be instructed to place the newborn's buttocks in warm water after having had a diaper on all night but not with every diaper change.

Neonatal red blood cells have a life span of 120 days, while those of adults last 80 to 100 days. a) True b) False

False Correct Explanation: Neonatal red blood cells have a life span of 80 to 100 days. The adult red blood cell life span is 120 days.

Is the following statement true or false? The nurse caring for an infant with strabismus tells the concerned parent that there is no need to correct the visual disorder until the child reaches school age.

False. The nurse caring for a child with strabismus accurately explains to the parents that treatment should begin in infancy in order to preserve normal development of visual acuity. Rationale: Children with strabismus cannot focus properly, therefore cannot successfully develop visual acuity. The infant brain needs to be able to process the correctly fused image in order to develop the part of the brain responsible for visual perception.

You have been working with an adolescent with an eating disorder for several days. What is an indication that she is developing trust in you?

Her telling you that she is still inducing vomiting after each meal An adolescent has to be able to trust an adult before she can share confidences.

A male newborn is born with hypospadias. The nurse doing the newborn physical assessment notes that the penis is also curved downward. What information would the nurse provide the parents for this infant?

His ability to void and have an erection in adulthood may be impaired and surgery is needed. Hypospadias is a relatively common malformation of the male genital organ. It is an abnormal positioning of the urinary meatus on the underside of the penis. It is often accompanied by a downward bowing of the penis (chordee), which can lead to urination and erection problems in adulthood. There are no maneuvers that will improve the penis curvature, surgery is definitely warranted and needed, and infants with hypospadius are never circumcised because the foreskin may be needed for later repairs.

The nurse observes a newborn. He notes that the respiratory rate is 66, the nostrils flare out, and the newborn makes a grunting sound during respiration. What does the nurse conclude from these findings? The infant is: a) Burning brown fat b) Cold-stressed c) In respiratory distress d) Experiencing radiation heat loss

In respiratory distress Correct Explanation: The assessment findings discussed are signs of respiratory distress. An infant with a respiratory rate of greater than 60 with noise requires further assessment. All newborns burn brown fat to produce heat for their bodies. This is not something the nurse can assess. The scenario described does not indicate that the newborn is cold-stressed nor experiencing radiation heat loss. Therefore options A, B and D are incorrect.

The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client? Injecting the medication into the vastus lateralis Injecting 1cc of medication Using a 21-gauge needle Injecting at a 45-degree angle

Injecting the medication into the vastus lateralis Use of the vastus lateralis is the preferred site for administration of the medication. The nurse would use a 22- to 25-gauge needle and inject 0.5 cc's of medication at a 90-degree angle.

The nurse is caring for a newborn after the parents have spent time bonding. As the nurse performs the assessment and evidence-based care, which eye care will the nurse prioritize? Instill 0.5% ophthalmic erythromycin. Watch for signs of eye irritation. Instill 0.5% ophthalmic silver nitrate. Instill 0.5% ophthalmic tetracycline.

Instill 0.5% ophthalmic erythromycin. The standard eye care to prevent ophthalmia neonatorum is 0.5% erythromycin ointment or 1% tetracycline eye drops. Although 1% silver nitrate drops were once used, it has been discontinued due to its ineffectiveness. The nurse would not wait to see if the eyes show signs of irritation before administering the medication. Delaying could lead to preventable blindness.

Preterm infants have more fragile capillaries in the periventricular area than term infants. This put these infants at risk for which problem?

Intracranial hemorrhaging Fragile capillaries in the periventricular area of the brain put preterm infants at risk for intracranial hemorrhage. Closure of the fontanels has nothing to do with fragile capillaries within the brain. Larger head size gives children a higher center of gravity which causes them to hit their head more readily. Congenital hydrocephalus may be caused by abnormal intrauterine development or infection

What should the nurse expect for a full-term newborn's weight during the first few days of life? a) Loss of 5% to 10% of the birth weight in the first few days in breastfed infants only b) A formula-fed newborn should gain 3% to 5% of the initial birth weight in the first 48 hours, but a breastfed newborn may lose up to 3%. c) Loss of 5% to 10% of birth weight in formula-fed and breastfed newborns d) An increase in 3% to 5% of birth weight by day 3 in formula-fed babies

Loss of 5% to 10% of birth weight in formula-fed and breastfed newborns Correct Explanation: The nurse should expect the newborn who is breastfed or formula-fed to lose 5% to 10% of birth weight in the first few days of life.

The nurse is examining a child with fetal alcohol syndrome (FAS). Which assessment finding should the nurse expect?

Low nasal bridge with short upturned nose Typical FAS facial features include a low nasal bridge with short upturned nose, flattened midface, and a long philtrum with narrow upper lip. Microcephaly rather than macrocephaly is associated with FAS. Clubbing of fingers is associated with chronic hypoxia.

Which nursing measure is most effective in reducing newborn infections?

Maintain medical asepsis while providing care. Nurses possess the education and assessment tools to decrease the incidence of and reduce the impact of newborn infections. Nurses should implement measures for prevention and early recognition, including maintaining medical and surgical asepsis for all providing care. Nurses should outline and carry out measures to prevent hospital-acquired infections, such as thorough hand-washing hygiene for all staff.

When assessing infant reflexes, the nurse documents a startled response and extension of the arms and legs as which reflex? Moro tonic neck rooting fencing

Moro The Moro reflex is also known as the startle reflex. When the infant is startled they extend their arms and legs away from the body. The fencing reflex is also called the tonic neck reflex and is a total body assessment. The rooting reflex assesses the infant's ability to "look" for food.

When assessing infant reflexes the nurse documents a startled response and extension of the arms and legs as which reflex? a) Rooting b) Moro c) Tonic neck d) Fencing

Moro Correct Explanation: The moro reflex is also known as the startle reflex. When the infant is startled they extend their arms and legs away from the body. The fencing reflex is also called the tonic neck reflex and is a total body assessment. The rooting reflex assesses the infant's ability to "look" for food.

The nurse caring for an infant with craniosynostosis, specifically positional plagiocephaly, should prioritize which activity?

Moving the infant's head every 2 hours Positional plagiocephaly can occur because the infant's head is allowed to stay in one position for too long. Because the bones of the skull are soft and moldable, they can become flattened if the head is allowed to remain in the same position for a long period of time. Massaging the scalp will not affect the skull. Measuring the intake and output is important but has no effect on the skull bones. Small feedings are indicated whenever an infant has increased intracranial pressure, but feeding an infant each time he fusses is inappropriate care.

Any individual taking phenobarbital for a seizure disorder should be taught:

Never to discontinue the drug abruptly. Phenobarbital should always be tapered, not stopped abruptly, or seizures from the child's dependency on the drug can result.

A nursing student is preparing a class for new mothers about adaptations they can expect in their newborns. Which of the following about newborn vision whould the student accurately include in the presentation? a) Newborns cannot focus on any objects. b) Newborns have the ability to focus only on objects in close proximity. c) Newborns have the ability to focus only on objects far away. d) Newborns have the ability to focus on objects in midline.

Newborns have the ability to focus only on objects in close proximity. Correct Explanation: In regards to vision the newborn has the ability to focus on objects only in close proximity (7 to 12 inches away) and tracks objects in midline or beyond. Vision is the least mature sense at birth.

When teaching parents of a child with encopresis, what would you stress?

Not punishing the child for encopresis Encopresis (inappropriate soiling of stool) is a symptom of an underlying stress or disease. The child needs therapy to determine the cause.

A nurse is caring for a newborn with transient tachypnea. What nursing interventions should the nurse perform while providing supportive care to the newborn? Select all that apply. Observe respiratory status frequently. Massage the newborn's back. Provide warm water to drink. Ensure the newborn's warmth. Provide oxygen supplementation.

Observe respiratory status frequently. Ensure the newborn's warmth. Provide oxygen supplementation. The nurse should give the newborn oxygen, ensure the newborn's warmth, and observe the newborn's respiratory status frequently. The nurse need not give the newborn warm water to drink or massage the newborn's back.

A nurse demonstrates understanding of the various levels of consciousness as they progress from most alert to least alert. Place the levels of consciousness in the order that reflects this progression.

Oriented to person, place, and time Disorientation Obtundation Stupor Coma

The nurse is caring for a 10-year-old girl with an anxiety disorder. During a physical examination, which physical finding would the nurse expect?

Patches of hair loss Patches of hair loss that occur with repetitive hair twisting or pulling are associated with anxiety. Watery, dilated eyes and the absence of nasal hair are often signs of substance abuse

A mother is telling the school nurse about her concerns regarding her 13-year-old daughter, who is experiencing headaches. Her grades have dropped, and she is sleeping late and going to bed early every night. The nurse advises the mother that the first priority should be to:

Schedule an immediate history and physical examination. The first step is to conduct a physical examination to rule out or identify illnesses or physical problems that might cause depression. Once any physical causes have been ruled out, the health care team can determine the most appropriate approach to assess the girl's symptoms.

A group of nursing students are reviewing the actions of various drugs used to treat mental health disorders in children. The students demonstrate understanding of the information when they identify which drug as potentiating the activity of serotonin in the brain?

Sertraline Sertraline is a selective serotonin reuptake inhibitor that potentiates serotonin activity in the brain. Trazodone is an atypical antidepressant that inhibits the reuptake of serotonin. Lithium influences the reuptake of serotonin and/or norepinephrine. Buspirone blocks the reuptake of dopamine

The nurse is doing a presentation on the diagnosis of anorexia nervosa to a group of pediatric nurses. Which clinical manifestations would the nurse teach this group to observe for in the adolescent with anorexia nervosa?

Soft and sparse body hair Persons with anorexia are visibly emaciated, with an almost skeleton-like appearance. They appear sexually immature, have dry skin and brittle nails, and often have soft, sparse body hair. Other symptoms include amenorrhea (absence of menstruation), constipation, hypothermia, bradycardia, low blood pressure, and anemia

A 6-week gestation client asks the nurse what foods she should eat to help prevent neural tube disorders in her growing baby. The nurse would recommend which foods?

Spinach, oranges, and beans Folic acid assists in preventing the incidence of neural tube disorders. These foods include green, leafy vegetables, citrus fruits, beans, and fortified breads, cereals, rice, and pasta. Milk, yogurt, and cheese are high in calcium. Bananas, avocados, and coconut are high in potassium. Pork, beans, and poultry are high in iron.

The nurse is preparing the delivery room before the birth occurs. What supplies would the nurse have available to care for the newborn? Select all that apply. Suction equipment Glucose water Identification bands Warmer bed Ophthalmoscope

Suction equipment Identification bands Warmer bed In preparing the delivery room, the nurse should preheat a warmer bed, have suction equipment at bedside, and have the identification bands ready for both the mother and newborn. Glucose water and an ophthalmoscope are not needed immediately after delivery to stabilize the newborn.

The nurse is developing a plan of care for a neonate experiencing symptoms of drug withdrawal. What should be included in this plan?

Swaddle the infant between feedings. Supportive interventions to promote comfort include swaddling, low lighting, gentle handling, quiet environment with minimal stimulation, use of soft voices, pacifiers to promote "self-soothing," frequent small feedings, and vertical rocking, which will soothe the newborn's neurological system.

Which is an example of impaired adaptive functioning in a 8/9-year-old girl/boy with a developmental disorder?

The child cannot properly dress his/herself. A child with impaired adaptive functioning would not be able to dress himself properly, if at all. The inability to copy a phone number or sentence or to read well reflects learning disorders.

Which sign or symptom suggests that a 5-year-old boy who does not maintain eye contact or speak may have autism spectrum disorder (ASD)?.

The child constantly opens and closes his hands/The child constantly pats his legs. Repetitive motor mannerisms such as constantly opening and closing the hands are a typical behavior pattern for ASD. A high level of activity and inattentiveness are typical symptoms of mental retardation. Decrease in head circumference suggests malnutrition or decelerating brain growth. A long face and prominent jaw are symptoms of fragile X syndrome

The nurse is collecting data on an 18-month-old old child with a diagnosis of autism spectrum disorder (ASD). What clinical manifestation would likely have been noted in the child with this diagnosis?

The child does not make eye contact. Children with ASD often display hyperactivity, aggression, temper tantrums, or self-injury behaviors, such as head banging or hand biting. They may resist cuddling, lack eye contact, be indifferent to touch or affection, and have little change in facial expression. They do not develop a smiling response to others nor an interest in being touched or cuddled. In fact, they can react violently to attempts to hold them. They do not show the normal fear of separation from parents that most toddlers exhibit. Often they seem not to notice when family caregivers are present.

The nurse is interviewing the caregivers of a child brought to the emergency unit. The caregiver states, "She has a history of seizures but this time it lasted more than 30 minutes and she just keeps having them." The most accurate description of this child's condition would be:

The child is in status epilepticus. Status epilepticus is the term used to describe a seizure that lasts longer than 30 minutes or a series of seizures in which the child does not return to his or her previous normal level of consciousness. The child likely is having generalized seizures, but the most accurate description of what is happening is status epilepticus. With infantile spasms, muscle contractions are sudden, brief, symmetrical, and accompanied by rolling eyes. With absence seizures the child loses awareness and stares straight ahead but does not fall.

What finding would suggest that a 5-year-old boy might have a developmental disorder?

The child is not able to follow directions. A 5-year-old child should be able to follow simple directions. If he is unable to do this, he has not yet achieved a developmental milestone. Brushing his teeth with supervision and knowing cat and dog sounds are normal for this age. Having trouble with r, l, and y sounds is not unusual and may continue until age 7

In caring for a child with a seizure disorder, the primary goal of treatment is:

The child will be free from injury during a seizure. Keeping the child free from injury is the highest priority goal. The other choices are important, but keeping the child safe is higher than the anxiety or knowledge deficit concerns. The physical always is a priority over the psychological.

The nurse is working with school-age children who are having enuresis or encopresis. What will most likely be the first step in this child's treatment?

The child will have a complete physical exam. The child with enuresis or encopresis may have a physiologic or psychological cause and may indicate a need for further exploration and treatment. A complete physical exam and assessment is done first to rule out any physical cause.

The nurse is caring for a newborn with respiratory distress syndrome (RDS). Which explanation best explains this disorder?

The infant's lungs are immature and deficient in surfactant. In RDS, the premature infant's lungs are deficient in surfactant and thus collapse after each breath, greatly increasing the work of breathing. The immature liver in the preterm infant cannot manage all the bilirubin produced by hemolysis (destruction of red blood cells with the release of hemoglobin), making the infant prone to jaundice and high blood bilirubin levels. Intraventricular hemorrhage (IVH) is a complication of preterm birth in which there is bleeding into the brain's ventricles. Retinopathy of prematurity (ROP) is a form of retinopathy (degenerative disease of the retina) commonly associated with the preterm newborn.

A nurse is assessing a newly admitted newborn who is 2 hours old. Which assessment findings would concern the nurse? Select all that apply.

The newborn has visible bilateral nasal flaring. The newborn has visible chest retractions The signs and symptoms of respiratory distress include tachypnea, periodic breathing, apnea, retractions, nasal flaring, grunting, pallor, and cyanosis. These findings require interventions. The blue hands and feet, apical pulse rate, and minimal response to voices are all appropriate for a newborn who is two hours old.

The nurse is caring for a newborn with hemolytic disease of the newborn who is receiving phototherapy. Which nursing intervention would be the most appropriate for the nurse to do?

The nurse turns the newborn every 3 or 4 hours. The nurse should turn the newborn every 3 or 4 hours to rotate the area of exposure. Do not turn off the lights except to feed and to change the diaper. The infant is nude to maximize the skin surface area exposed to the light. Remove the patches every four hours to cleanse the eyes and examine for irritation, inflammation, and/or dryness. Clean and change the patches daily.

Which of the following is true regarding fetal and newborn senses? a) A fetus is unable to hear in utero. b) A newborn cannot see until several hours after birth. c) The rooting reflex is an example that the newborn has a sense of touch. d) A newborn cannot experience pain. e) A newborn does not have the ability to discriminate between tastes.

The rooting reflex is an example that the newborn has a sense of touch. Correct Explanation: Newborns experience pain, have vision, and can discriminate between tastes. The rooting reflex is an example of a newborn's sense of touch. The fetus can hear in utero.

Which of these age groups has the highest actual rate of death from drowning?

Toddlers Toddlers and older adolescents have the highest actual rate of death from drowning.

The nurse is assessing a 6-year-old with attention deficit/hyperactivity disorder (ADHD). The nurse observes the boy making repeated clicking noises and notes he has a slight grimace. The nurse recommends the boy receive further evaluation for:

Tourette syndrome. Repeated vocal tics such as sniffling, grunting, clicking, or word utterances are associated with Tourette syndrome. The syndrome consists of multiple motor tics and one or more motor tics occurring simultaneously at different times. ADHD and obsessive-compulsive disorder occur in 90% of children with Tourette syndrome. Vocal and motor tics are not typical indicators of Asperger syndrome, anxiety disorder, or autism spectrum disorder.

Many children with autistic spectrum disorder (ASD) are intellectually disabled.

True Many children with ASD are intellectually disabled, requiring lifelong supervision.

Is the following statement true or false? The nurse caring for children with visual disorders accurately states that the most common visual difficulty seen in children is refractive errors.

True. The most common visual difficulty seen in children is refractive errors. Rationale: Refractive errors occur when the light that enters the lens does not bend appropriately to allow it to fall directly on the retina.

Since newborns are at risk to contract infections, what is the best measure the nurse can teach parents to implement to prevent the newborn from getting ill? Keeping the infant's cord clean and dry Washing their hands before handling the infant Rooming-in with their infant Using gloves when handling their infant

Washing their hands before handling the infant Hand washing is the best way to prevent infections in newborn infants. Even the nursery personnel are required to perform a hand scrub before beginning their work in most nurseries. Rooming-in reduces the risk of cross-contamination but is not nearly as important as good hand washing.

At what point should the nurse expect a healthy newborn to pass meconium? a) By 12 to 18 hours of life b) Within 24 hours after birth c) Within 1 to 2 hours of birth d) Before birth

Within 24 hours after birth Correct Explanation: The healthy newborn should pass meconium within 24 hours of life.

The neonatal intensive care nurse is assessing a new admission and suspects the newborn to have meconium aspiration syndrome. Which assessment finding would correlate with the nurse's suspicion?

a barrel-shaped chest with an increased anterior-posterior chest diameter Observe the newborn with MAS for a barrel-shaped chest with an increased anterior-posterior chest diameter, prolonged tachypnea, progression of respiratory distress, intercostal retractions, end-expiratory grunting, and cyanosis. Arterial blood gas analysis will indicate metabolic acidosis with a low blood pH, decreased PaO2, and increased PaCO2. The arterial blood gas values listed are normal as well as the vital signs. Acrocynosis is a normal expectation of a newborn immediately after birth.

In the infant diagnosed with spina bifida with myelomeningocele, the infant will likely have:

a partial to complete paralysis in the lower extremities. In spina bifida with myelomeningocele, there is a protrusion of the spinal cord and the meninges, with nerve roots embedded in the wall of the cyst. The effects of this defect vary in severity from sensory loss or partial paralysis below the lesion to complete flaccid paralysis of all muscles below the lesion.

A nurse is caring for a neonate of 25 weeks' gestation who is at risk for intraventricular hemorrhage (IVH). Which assessment finding should be reported immediately?

a sudden drop in hemoglobin The signs and symptoms of IVH include a sudden decrease in hematocrit, a severe and sudden unexplained deterioration of vital signs, bulging fontanels, changes in activity level, and sudden lethargy. The diagnosis is confirmed by cranial ultrasonography. Pink skin with blue extremities is not a critical sign of IVH, nor is the routine calculation of intake and output a critical assessment for IVH.

When providing care to a newborn with necrotizing enterocolitis (NEC), the nurse would need to report which finding immediately?

abdomen appearing red and shiny An abdomen that appears red and shiny in a newborn with NEC indicates peritonitis and must be reported immediately. A decrease in abdominal girth, stools negative for blood, and active bowel sounds suggest that the condition is resolving.

A nurse is reading a journal article about birth defects and finds that some birth defects are preventable. Which risk factor would the nurse expect to find as being cited as the current leading preventable cause of birth defects?

alcohol Alcohol is now recognized as the leading preventable cause of birth defects and developmental disorders in the United States. Smoking, recreational drugs, and obesity are also contributing factors.

The drug most commonly abused by children and adolescents is:

alcohol. Alcohol abuse occurs when a person ingests a quantity sufficient to cause intoxication. It is also the most commonly abused drug among children and adolescents.

A nurse who has worked in a nursery for 15 years informs the nursing student that feeding an infant early has advantages and describes the biggest advantage as which of the following? a) allows the baby to sleep longer b) allows the baby to pass stools, which helps to reduce bilirubin c) allows the mother to see if the baby can tolerate formula d) helps to ease the baby's hunger

allows the baby to pass stools, which helps to reduce bilirubin Correct Explanation: Newborns fed early pass stools sooner, which helps to reduce bilirubin. The other options might be helpful but are not the most important reason for feeding a newborn early.

Assessment reveals that a young mother has several risk factors for giving birth to an infant with a neural tube defect. Which laboratory test would the nurse expect to be used to monitor the fetus for this birth defect?

alpha-fetoprotein levels In pregnancies in which the fetus has neural tube defect, the level of alpha-fetoprotein in the amniotic fluid and maternal serum is elevated. By monitoring this level throughout the pregnancy, it is possible to be aware of this defect before the birth. Genetic studies, folic acid levels, and cultures for infections are not utilized to detect neural tube defects.

After birth, an infant experiences meconium aspiration. What does the nurse anticipate the primary care provider prescribing prophylactically to prevent pneumonia?

antibiotics Prophylactic antibiotics may prevent development of pneumonia.

A preterm newborn is noted to be cyanotic. Which laboratory test will the nurse prepare the infant for to determine if the cyanosis is due to respiratory or circulatory problems?

arterial blood gases Arterial blood gases are obtained to determine the oxygenation levels and to help differentiate lung disease from heart disease. Chest X-rays will help identify cardiac size, shape, and position. An echocardiogram will evaluate the heart anatomy and flow defects. An angiography will be conducted to prepare for cardiac surgery, if needed.

What are the causes of retinopathy of the preterm newborn? Select all that apply.

assistive ventilation with high oxygen content fragility of blood vessels in the eyes in response to changes on oxygenation. shock Retinopathy of the preterm newborn typically develops in both the eyes secondary to an injury such as hyperoxemia resulting from prolonged assistive ventilation and high oxygen exposure, fragility of retinal blood vessels in response to changes in oxygentaion, and shock. Alkalosis does not contribute to this problem- acidosis does.

Which situation would cause the nurse to become concerned about possible hearing loss? a. 12-month old who babbles incessantly, making no sense b. 8-month old who says only "da" c. 3-month old who startles easily to sound d. 3-year old who drops the letter "s"

b. Infants should be babbling at the age of 8 months. Lack of babbling is an indicator of possible hearing loss.

A 2-year old has been prescribed eye patching for strabismus 6 hours per day. What teaching does the nurse provide for the mother? a. Try to patch 6 hours per day, but if you miss some it is OK. b. Patching is necessary to strengthen vision in the weaker eye. c. Patching will keep the eye from turning in. d. Since the child is so young, patching can be delayed until school age.

b. Patching instructions must be complied with. Patching is done as early as possible to strengthen the acuity in the weaker eye while vision is still developing. Delay in strabismus treatment may lead to amblyopia and eventual blindness in one or both eyes.

The parents are upset their newborn has a cleft lip. When describing the treatment, the nurse should mention that surgical repair can be done:

between the age of 6 to 12 weeks. Treatment of cleft lip is surgical repair between the ages of 6 to 12 weeks. It is important to repair this anomaly as soon as possible to facilitate bonding between the newborn and the parents and to improve nutritional status.

The nurse is assisting with a diagnostic test to determine the extent of effusion of the middle ear. What is the name for this test? a. Culture of ear discharge b. Tympanic fluid culture c. Tympanometry d. Tympanotomy

c. Tympanometry. Tympanometry determines effusion of the middle ear. Rationale: With tympanometry, a probe in the ear canal measures movement of the eardrum to determine effusion in the middle ear. Cultures determine specific bacteria present and appropriate antibiotic coverage. Tympanectomy is not a diagnostic test, but rather ear tubes surgery.

Forces of contractions, mild asphyxia, increased intracranial pressure, and cold stress all play a role in the newborn transition by releasing which of the following critical components? a) cortisol b) norepinephrine c) catecholamines d) epinephrine

catecholamines Correct Explanation: The physical forces of contractions at labor, mild asphyxia, increased intracranial pressure, and cold stress immediately experienced after birth lead to an increased release of catecholamines, which is critical for the changes involved in the transition to extrauterine life.

What is the term for a small collection of blood that forms underneath the skull as a result of birth trauma?

cephalhematoma Vernix caseosa is a thick white substance found on a newborn. Erythema toxicum is a newborn rash. Caput succedaneum is molding or edema.

Periventricular hemorrhage is suspected in a newborn of 30 weeks' gestation. The nurse would anticipate preparing the newborn for which diagnostic tool to confirm the diagnosis?

cranial ultrasound The diagnostic tool of choice to detect periventricular hemorrhage is a cranial ultrasound. Arterial blood gases would be helpful in evaluating for metabolic acidosis. Blood glucose levels provide information about the newborn's glucose stability. Chest X-ray would provide no information related to bleeding in the brain.

The nurse is caring for an infant born to a mother who abused cocaine during her pregnancy. The nurse would likely notice that this infant:

cries when touched. Developmental delays occur in young children of substance abusers. Infants of cocaine abusers do not like to be touched or held and avoid the caregiver's gaze, which contributes to bonding delays. Infants of cocaine abusers are often restless and below average weight when born.

A 4-year old complains of extreme pain when the tragus is touched. Though not diagnostic, this sign is most indicative of which disorder? a. acute otitis media b. acute tympanic effusion c. otitis interna d. otitis externa

d. Otitis externa, infection and inflammation of the ear canal, results in significant pain, particularly if the tragus is touched.

The nurse assesses an infant. Which finding may indicate heart failure?

diminished peripheral pulses After birth, the nurse should carefully assess the newborn's cardiovascular and respiratory systems, looking for signs and symptoms of respiratory distress, cyanosis, or congestive heart failure that might indicate a cardiac anomaly. Assess rate, rhythm, and heart sounds, reporting any abnormalities immediately. Note any signs of heart failure, including edema, diminished peripheral pulses, hepatomegaly, tachycardia, diaphoresis, respiratory distress with tachypnea, peripheral pallor, and irritability. Capillary refill time and the color of the infant's hands and feet are important to note, but do not indicate possible heart failure and neither does the blood glucose level.

The nurse is feeding a 2-day-old in the nursery when the infant begins choking and becomes cyanotic. Frothy sputum is observed coming from the mouth. What congenital malformation does the nurse understand these symptoms indicate?

esophageal atresia Any mucus or fluid that a newborn with esophageal atresial swallows enters the blind pouch of the esophagus. The pouch fills and overflows, usually resulting in aspiration into the trachea. The newborn with this disorder has frothing, excessive drooling, and periods of respiratory distress with choking and cyanosis.

A nurse in the newborn nursery has noticed that an infant is frothing and appears to have excessive drooling. Further assessment reveals that the baby has episodes of respiratory distress with choking and cyanosis. What disorder should the nurse suspect based on these findings?

esophageal atresia Any swallowed mucus or fluid enters the blind pouch of the esophagus when a newborn suffers from esophageal atresia. The newborn with this disorder will have frothing, excessive drooling, and periods of respiratory distress with choking and cyanosis. If this happens no feedings should be given until the newborn has been examined.

A nurse is assessing a newborn for jaundice. The nurse would first notice jaundice at which area?

face Neonatal jaundice first becomes visible in the face and forehead. Identification is aided by pressure on the skin, since blanching reveals the underlying color. Jaundice then gradually becomes visible on the trunk and extremities.

While assessing a newborn, the nurse notes that half the body appears red while the other half appears pale. The nurse interprets this finding as: stork bites. Mongolian spots. harlequin sign. erythema toxic.

harlequin sign. Harlequin sign refers to the dilation of blood vessels on only one side of the body. It gives a distinct midline demarcation, which is pale on one side and red on the opposite. Stork bites are superficial vascular areas found on the nape of the neck, eyelids, between the eyes and upper lip. Mongolian spots are blue or purple splotches that appear on the lower back and buttocks. Erythema toxicum is a benign, idiopathic, generalized, transient rash that resembles flea bites.

The AGPAR score is based on which 5 parameters? heart rate, breaths per minute, irritability, reflexes, and color heart rate, muscle tone, reflex irritability, respiratory effort, and color heart rate, breaths per minute, irritability, tone, and color heart rate, respiratory effort, temperature, tone, and color

heart rate, muscle tone, reflex irritability, respiratory effort, and color A newborn can receive an APGAR score ranging from 0 to 10. The score is based on 5 factors, each of which is assigned a 0, 1, or 2. Heart rate (should be above 100), muscle tone (should be able to maintain a flexion position), reflex irritability (newborn should cry or sneeze when stimulated), and respiratory effort are evaluted by the presence of a strong cry and by color. Color is evaluated by noting the color of the body and hands and feet.

Over the course of an eight-hour shift of postoperative care for a child who has had ventriculoatrial shunt placement, the nurse notes that the child's cry has become increasingly shrill and the child has projectile vomiting. The nurse would notify the primary care provider immediately because of the possibility that the child might be experiencing:

increased intracranial pressure. Symptoms of increased intracranial pressure (IICP) may include irritability, restlessness, personality change, high-pitched cry, ataxia, projectile vomiting, failure to thrive, seizures, severe headache, changes in level of consciousness, and papilledema. At least every 2-4 hours, the nurse should monitor the newborn's level of consciousness, check the pupils for equality and reaction, monitor the neurologic status, and observe for a shrill cry, lethargy, or irritability.

A preterm newborn is noted to have hypotonia, apnea, bradycardia, a bulging fontanelle, cyanosis, and increased head circumference. These signs indicate the newborn has which complication?

intraventricular hemorrhage (IVH) Signs that may accompany IVH include hypotonia, apnea, bradycardia, a full (or bulging) fontanelle, cyanosis, and increased head circumference.

In the infant with developmental dysplasia of the hip (DDH), which sign would likely be noted?

limited abduction of the affected hip The infant with DDH usually has limited abduction of the affected hip. They have asymmetry of the gluteal skin folds and shortening of the femur. Adduction is not a concern.

Which finding is common in the child who has a ventricular septal defect?

loud, harsh murmur Children with ventricular septal defects have a characteristic loud, harsh murmur. Fatigue and dyspnea, delayed growth and development, and a bounding pulse are seen in the child with patent ductus arteriosus

A premature infant in the neonatal intensive care unit exhibits worsening respiratory distress and is noted to have abdominal distention, absent bowel sounds, and frequent diarrhea stools that are positive for hemoccult. What diagnosis would be most likely to correlate with the symptoms?

necrotizing enterocolitis Observations for the developemnt of NEC in the preamture newborn may include feeding intolerance with abdominal distention tenderness and bloody or hemoccult-positive stools. Diarrhea is present with NEC and worsening of respiratory distress. Decreased or absent bowel sounds are noted. Rotavirus causes inflammation of a child's stomach and digestive tract, usually triggering vomiting, diarrhea, and fever and not seen in a preterm infant. Garamycin-resistant bacteria is usually seen in older adults.

The Ballard scoring system evaluates newborns on which two factors? body maturity and cranial nerve maturity physical maturity and neuromuscular maturity tone maturity and extremities maturity skin maturity and reflex maturity

physical maturity and neuromuscular maturity When determining a newborn's gestational age using the Ballard scale, the nurse assesses physical signs and neurologic characteristics.

A nursing student is aware that fetal gas exchange takes place in which of the following? a) placenta b) lungs c) bronchioles d) uterus

placenta Correct Explanation: Many different changes occur for the newborn to survive outside the uterus. One such change is that gas exchange that once took place in the placenta now will take place in the lungs.

The nurse is documenting assessment of infant reflexes. She strokes the side of the infant's face, and the baby turns toward the stroke. What reflex has the nurse elicited? tonic neck sucking Moro rooting

rooting This is the rooting reflex and is used to encourage the infant to feed. This reflex and the sucking reflex work together to assist the infant with cues for feeding at the breast. The tonic neck (or fencing) reflex and the Moro (or startle reflex) are total body reflexes and assess neurologic function in the newborn.

When evaluating neurologic maturity to determine gestational age, the nurse understands that which activity is not part of the assessment? square window rooting posture popliteal angle

rooting The six activities the newborn performs when being evaluated for gestational age based on neurologic maturity are as follows: posture, square window, arm recoil, popliteal angel, scar sign, and heel to ear.

When assessing a newborn, the nurse determines that the newborn is most likely experiencing respiratory distress syndrome (RDS) based on which finding?

see-saw respirations Typically the newborn with RDS demonstrates signs and symptoms of severe respiratory distress at birth or within a few hours of birth. Fine, inspiratory crackles are noted on auscultation of a newborn with RDS. See-saw respirations are characteristic of RDS. A newborn with RDS typically demonstrates generalized cyanosis.

What treatment can the nurse anticipate assisting with for a newborn with congenital talipes equinovarus?

serial casting Treatment for congenital talipes equinovarus starts during the neonatal period. Correction can usually be accomplished by manipulation and bandaging or by application of a cast. Casts are changed frequently to provide gradual, atraumatic correction—every few days for the first several weeks.

Dexamethasone is often prescribed for the child who has sustained a severe head injury. Dexamethasone is a(n):

steroid. A steroid may be prescribed to reduce inflammation and pressure on vital centers.

A nurse working in the neonatal nursery anticipates the physician to order which of the following for a premature newborn having difficulty breathing? a) albuteral b) epinephrine c) surfactant d) norepinephrine

surfactant Correct Explanation: Surfactant is a protein that keeps small air sacs in the lungs from collapsing. Its use was introduced in 1990 and continues today, especially for premature babies and those who have respiratory distress syndrome. The other medications are not given to help premature babies breathe.

A mother points out to you that following three meconium stools, her newborn has had a bright green stool. You would explain to her that a) this is a normal finding. b) her child will be isolated until the stool can be cultured. c) her child may be developing an allergy to breast milk. d) this is most likely a symptom of diarrhea.

this is a normal finding. Correct Explanation: Newborn stools typically pass through a pattern of meconium, green transitional, and then yellow.

The nurse is assessing the abdomen of the neonate. When inspecting the umbilical cord area of a newborn, the nurse would expect which finding? three arteries and no veins two arteries and two veins one artery and two veins two arteries and one vein

two arteries and one vein The normal umbilical cord contains three vessels: two arteries and one vein.

After completing a class for new parents, the nurse notes the session is successful when the class recognizes the newborn should be bathed how often? two or three times per week once a week once a day every other day

two or three times per week Bathing two or three times weekly is sufficient for the first year; more frequent bathing may dry the skin.

Following birth, the newborn's independent circulatory system is established. If there is an abnormal opening between the chambers in the heart, which cardiac defect may occur?

ventricular septal defect A ventricular septal defect is the most common intracardiac defect. It consists of an abnormal opening in the septum between the two ventricles.

An infant develops hydrocephalus at 2 weeks of age. Which finding would the nurse expect to assess?

white sclera showing above the pupils As accumulating cerebrospinal fluid puts pressure on the posterior surface of the eye globes, they tip downward; white sclera shows above the pupils.

A group of students are reviewing the role of neurotransmitters in the development of depression. The students demonstrate a need for additional study when they identify which neurotransmitter as being involved?

γ-Aminobutyric acid (GABA) Both norepinephrine and dopamine play a role in mood. When alterations in the neurotransmission of norepinephrine and dopamine occur, the symptoms of depression (apathy, loss of interest and pleasure) result. Decreased levels of serotonin have also been implicated in depressive symptoms. GABA is associated with anxiety disorders

The nurse is caring for a 6-year-old child with an external ventricular drainage device. The nurse is concerned about the minimal drainage in the past few hours. What actions by the nurse are indicated?

• Check tubing clamps to ensure they are open. • Ensure the tubing is not kinked. Nursing care of an external ventricular drainage device requires the nurse ensure all connections are secure and labeled. The amount of drainage requires close observation. If drainage is absent or minimal the nurse must assess the tubing to make certain it is not clamped or kinked. The level of the drip chamber must be set at the height of the child (at the clavicle). Taking the temperature will be useful to assess for the presence of infection but that is not currently a concern. Asking the child to cough and deep breathe should not be done. Deep breathing is beneficial for all postoperative clients, but coughing may increase pressures and should be avoided.

The nurse is using the pediatric Glasgow Coma Scale to assess a child's level of consciousness. What would the nurse assess?

• Eye opening • Verbal response • Motor response

When assessing a neonate for seizures, what would the nurse expect to find?

• Tachycardia • Elevated blood pressure • Jitteriness • Ocular deviation Neonatal seizures may be difficult to recognize but may be manifested by tremors, jitteriness, tachycardia and elevated blood pressure, and ocular deviation. Tonic-clonic contractions typically are more common in older children.

The nurse is recording vital signs in the client diagnosed with complications of anorexia nervosa. Which findings are consistent with the condition?

• Weak pulse • Orthostatic hypotension • Hypothermia Anorexia nervosa is a condition most commonly seen in adolescents. In this condition the individual is obsessed with body weight. There is a noted loss of weight. The vital signs frequently display orthostatic hypotension, irregular and decreased pulse, or hypothermia

The prenatal health nurse is conducting an educational session focusing on alcohol use during pregnancy. The nurse feels the session was a success when a participant makes which statement?

"Alcohol use could cause my baby to be cognitively challenged." Disorders included in the grouping fetal alcohol spectrum disorders are alcohol-related neurodevelopmental disorders (ARND). Children with ARND primarily display intellectual disabilities related to behavior and learning. Fetal alcohol syndrome is one of the most common known causes of cognitive challenge. Counsel girls and women to avoid any alcohol use during pregnancy. Participating in programs for at-risk groups, including adolescents, especially about the serious effects of substance abuse, especially alcohol, during pregnancy.

A nurse teaches new parents about how to soothe their crying newborn. Which statement by the parents indicates that they understand how to soothe their newborn if he becomes upset? "We'll turn the mobile on that's hanging above his head in his crib." "We'll place him on his belly on a blanket on the floor." "We'll hold off on feeding him for a while because he might be too full." "We'll vigorously rub his back as we play some music."

"We'll turn the mobile on that's hanging above his head in his crib." Turning on a mobile above the newborn's head is helpful in calming the newborn. The movement is distracting, and the music is comforting. The newborn's back should be rubbed lightly while the parents speak softly to him. Swaddling the newborn rather than having him lie on a blanket on the floor provides security and comfort. Feeding or burping can be helpful in relieving air or stomach gas.

What is the expected range for respirations in a newborn? 20 to 40 breaths per minute 40 to 80 breaths per minute 10 to 30 breaths per minute 30 to 60 breaths per minute

30 to 60 breaths per minute Although episodic breathing is normal and short periods of apnea can occur, the normal respiratory rate for a newborn is 30 to 60 breaths per minute. For adults, it is typically 8 to 20 breaths per minute.

A nursing instructor is describing common problems associated with preterm birth. When describing the preterm newborns risk for perinatal asphyxia, the instructor includes which of the following as contributing to the newborns risk? (Select all that apply.) A) Surfactant deficiency B) Placental deprivation C) Immaturity of the respiratory control centers D) Decreased amounts of brown fat E) Depleted glycogen stores

A) Surfactant deficiency C) Immaturity of the respiratory control centers

A nurse is assessing a newborn who has been classified as small for gestational age. Which of the following would the nurse expect to find? (Select all that apply.) A) Wasted extremity appearance B) Increased amount of breast tissue C) Sunken abdomen D) Adequate muscle tone over buttocks E) Narrow skull sutures

A) Wasted extremity appearance C) Sunken abdomen E) Narrow skull sutures

An LGA newborn has a blood glucose level of 30 mg/dL and is exhibiting symptoms of hypoglycemia. Which of the following would the nurse do next? A)Administer intravenous glucose immediately. B)Feed the newborn 2 ounces of formula. C)Initiate blow-by oxygen therapy. D)Place the newborn under a radiant warmer.

A)Administer intravenous glucose immediately.

SHORT ANSWER 1. A toddler with leukemia is on intravenous chemotherapy treatments. The toddlers lab results are WBC: 1000; neutrophils: 7%; nonsegmented neutrophils (bands): 7%. What is this childs absolute neutrophil count (ANC)? (Record your answer in a whole number.)

ANS 140: To calculate an ANC for a WBC = 1000; neutrophils = 7%; and nonsegmented neutrophils (bands) = 7%, the steps are Step 1: 7% + 7% = 14%. Step 2: 0.14 1000 = 140 ANC.

10. When both parents have sickle cell trait, which is the chance their children will have sickle cell anemia? a. 25% b. 50% c. 75% d. 100%

ANS: A Sickle cell anemia is inherited in an autosomal recessive pattern. If both parents have sickle cell trait (one copy of the sickle cell gene), then for each pregnancy, a 25% chance exists that their child will be affected with sickle cell disease. With each pregnancy, a 50% chance exists that the child will have sickle cell trait. Percentages of 75% and 100% are too high for the children of parents who have sickle cell trait.

13. Meperidine (Demerol) is not recommended for children in sickle cell crisis because it: a. may induce seizures. b. is easily addictive. c. is not adequate for pain relief. d. is given by intramuscular injection.

ANS: A A metabolite of meperidine, normeperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. Patients with sickle cell disease are particularly at risk for normeperidine-induced seizures. Meperidine is no more addictive than other narcotic agents. Meperidine is adequate for pain relief. It is available for IV infusion

26. A young boy will receive a bone marrow transplant (BMT). This is possible because one of his older siblings is a histocompatible donor. Which is this type of BMT called? a. Syngeneic b. Allogeneic c. Monoclonal d. Autologous

ANS: B Allogeneic transplants are from another individual. Because he and his sibling are histocompatible, the BMT can be done. Syngeneic marrow is from an identical twin. There is no such thing as a monoclonal BMT. Autologous refers to the individuals own marrow.

14. A school-age child is admitted in vasoocclusive sickle cell crisis. The childs care should include: a. correction of acidosis. b. adequate hydration and pain management. c. pain management and administration of heparin. d. adequate oxygenation and replacement of factor VIII.

ANS: B The management of crises includes adequate hydration, minimization of energy expenditures, pain management, electrolyte replacement, and blood component therapy if indicated. Hydration and pain control are two of the major goals of therapy. The acidosis will be corrected as the crisis is treated. Heparin and factor VIII is not indicated in the treatment of vasoocclusive sickle cell crisis. Oxygen may prevent further sickling, but it is not effective in reversing sickling because it cannot reach the clogged blood vessels.

2. Parents of a school-age child with hemophilia ask the nurse, Which sports are recommended for children with hemophilia? Which sports should the nurse recommend? (Select all that apply.) a. Soccer b. Swimming c. Basketball d. Golf e. Bowling

ANS: B, D, E Because almost all persons with hemophilia are boys, the physical limitations in regard to active sports may be a difficult adjustment, and activity restrictions must be tempered with sensitivity to the childs emotional and physical needs. Use of protective equipment, such as padding and helmets, is particularly important, and noncontact sports, especially swimming, walking, jogging, tennis, golf, fishing, and bowling, are encouraged. Contact sport such as soccer and basketball are not recommended.

35. Which is caused by a virus that primarily infects a specific subset of T lymphocytes, the CD4+ T cells? a. Wiskott-Aldrich syndrome b. Idiopathic thrombocytopenic purpura c. Acquired immunodeficiency syndrome (AIDS) d. Severe combined immunodeficiency disease

ANS: C AIDS is caused by the human immunodeficiency virus (HIV), which primarily attacks the CD4+ T cells. Wiskott-Aldrich syndrome, idiopathic thrombocytopenic purpura, and severe combined immunodeficiency disease are not viral illnesses.

3. The nurse is planning activity for a 4-year-old child with anemia. Which activity should the nurse plan for this child? a. Game of hide and seek in the children's outdoor play area b. Participation in dance activities in the playroom c. Puppet play in the child's room d. A walk down to the hospital lobby

ANS: C Because the basic pathologic process in anemia is a decrease in oxygen-carrying capacity, an important nursing responsibility is to assess the child's energy level and minimize excess demands. The child's level of tolerance for activities of daily living and play is assessed, and adjustments are made to allow as much self-care as possible without undue exertion. Puppet play in the childs room would not be overly tiring. Hide and seek, dancing, and walking to the lobby would not conserve the anemic childs energy

Therapy 16. Which statement best describes b-thalassemia major (Cooley anemia)? a. All formed elements of the blood are depressed. b. Inadequate numbers of red blood cells are present. c. Increased incidence occurs in families of Mediterranean extraction. d. Increased incidence occurs in persons of West African descent.

ANS: C Individuals who live near the Mediterranean Sea and their descendants have the highest incidence of thalassemia. An overproduction of red cells occurs. Although numerous, the red cells are relatively unstable. Sickle cell disease is common in persons of West African descent.

20. Parents of a hemophiliac child ask the nurse, Can you describe hemophilia to us? Which response by the nurse is descriptive of most cases of hemophilia? a. Autosomal dominant disorder causing deficiency in a factor involved in the bloodclotting reaction b. X-linked recessive inherited disorder causing deficiency of platelets and prolonged bleeding c. X-linked recessive inherited disorder in which a blood-clotting factor is deficient d. Y-linked recessive inherited disorder in which the red blood cells become moon-shaped

ANS: C The inheritance pattern in 80% of all of the cases of hemophilia is X-linked recessive. The two most common forms of the disorder are factor VIII deficiency, hemophilia A or classic hemophilia; and factor IX deficiency, hemophilia B or Christmas disease. The inheritance pattern is X-linked recessive. The disorder involves coagulation factors, not platelets, and does not involve red cells or the Y chromosomes.

27. Which is the most effective pain-management approach for a child who is having a bone marrow aspiration? a. Relaxation techniques b. Administration of an opioid c. EMLA cream applied over site d. Conscious or unconscious sedation

ANS: D Effective pharmacologic and nonpharmacologic measures should be used to minimize pain associated with procedures. For bone marrow aspiration, conscious or unconscious sedation should be used. Relaxation, opioids, and EMLA can be used to augment the conscious or unconscious sedation.

ESSAY 1. The nurse has initiated a blood transfusion on a preschool child. The child begins to exhibit signs of a transfusion reaction. Place in order the interventions the nurse should implement sequencing from the highest priority to the lowest. Provide answer using lowercase letters separated by commas (e.g., a, b, c, d). a. Take the vital signs. b. Stop the transfusion. c. Notify the practitioner. d. Maintain a patent IV line with normal saline.

ANS: b, a, d, c If a blood transfusion reaction of any type is suspected, stop the transfusion, take vital signs, maintain a patent IV line with normal saline and new tubing, notify the practitioner, and do not restart the transfusion until the childs condition has been medically evaluated.

A newborn is receiving ampicillin and gentamicin every 12 hours. When would this client have his hearing screen performed? 1 day after birth After the newborn has completed the antibiotic therapy Before discharge from the hospital 1 month after discharge

After the newborn has completed the antibiotic therapy It is recommended that all newborns undergo a hearing screening before they are discharged from the hospital. If the newborn is treated with an ototoxic medication such as gentamycin, the hearing screen must be conducted after completion of the antibiotic therapy.

The nurse prepares to assess a newborn who is considered to be large for gestational age (LGA). Which of the following would the nurse correlate with this gestational age variation? A)Strong, brisk motor skills B)Difficulty in arousing to a quiet alert state C)Birth weight of 7 lb 14 oz D)Wasted appearance of extremities

B)Difficulty in arousing to a quiet alert state

How can new parents aid their newborn to develop trust so the infant can become more organized in the responses to his or her environment? Allow the newborn opportunities to self-soothe by crying himself to sleep. Place the infant in an open crib to allow freedom of movement. Be attentive to the basic needs of the infant and be consistent. Have the parents place the infant on a schedule as soon as possible.

Be attentive to the basic needs of the infant and be consistent. To enhance an infant's organization and develop a sense of trust, parents need to consistently meet the infant's needs through feedings, holding him and keeping him dry. Swaddling, not allowing freedom of movement, also helps the infant feel secure. Self-soothing at this age is discouraged because the infant needs to feel that someone is always there and attentive to his needs.

Which is NOT a cause of jaundice in the newborn? a) Bilirubin hyperexcretion b) Bilirubin overproduction c) Impaired bilirubin excretion d) Decreased bilirubin conjugation

Bilirubin hyperexcretion Correct Explanation: Overexcretion of bilirubin would not cause jaundice. Bilirubin overproduction, decreased bilirbuin conjugation, and impaired bilirubin excretion would cause hyperbilirubinemia, which leads to jaundice. (

A newborn's axillary temperature is 97.5 °F. He has a cap on his head. His T-shirt is damp with spit-up milk. His blanket is laid over him, and several children are in the room running around his bassinet. The room is comfortably warm, and the bassinet is beside the mother's bed away from the window and doors. What are the most likely mechanisms of heat loss for this newborn? a) Convection and evaporation b) Convection and radiation c) Conduction and evaporation d) Conduction and radiation

Convection and evaporation Correct Explanation: Conductive heat loss occurs when the newborn's skin touches a cold surface, causing body heat to transfer to the colder object. Heat loss by convection happens when air currents blow over the newborn's body. Evaporative heat loss happens when the newborn's skin is wet. As the moisture evaporates from the body surface, the newborn loses body heat along with the moisture. Heat loss also occurs by radiation to a cold object that is close to, but not touching, the newborn.

The nurse is collecting data from the caregiver of an 8-year-old child who recently started soiling his underwear each day rather than using the toilet to defecate. This behavior indicates a symptom of:

Encopresis Encopresis is chronic involuntary fecal soiling beyond the age when control is expected (about 3 years of age).

Which of the following laboratory test results would the nurse consider as a normal finding in a newborn soon after birth? a) Platelets: 400,000/uL b) Red blood cells: 3,500,000/uL c) Hemoglobin: 17.5 g/dL d) White blood cells: 5,000/mm3

Hemoglobin: 17.5 g/dL Correct Explanation: Hemoglobin typically ranges from 17 to 20 g/dL. White blood cells are initially elevated soon after birth as a result of birth trauma, typically ranging from 10,000 to 30,000/mm3. The newborn's platelet count is the same as that for an adult, ranging between 100,000 and 300,000/uL. After birth, the red blood cell count gradually increases as the cell size decreases. Normal count ranges from 5,100,000 to 5,800,000/uL.

The nurse is explaining to new parents the various injections their newborn will receive before being discharged home. Which injection should the nurse teach the parents about that will help decrease the incidence of hepatic disease later in life? Vitamin K HiB Hep B HBV immunoglobin

Hep B Hep B is the vaccination against hepatitis B and recommended by the CDC. It has been found to help prevent cirrhosis and liver cancer later in life. The HBV immunoglobin may be given in conjunction with the hep B if the mother is found to be HBV positive. The HiB is given later, usually at the 2-month visit.

The nurse is admitting a 15-year-old female with severe weight loss from anorexia nervosa. She also has a fluid and electrolyte imbalance. The nurse is preparing the care plan. Which nursing diagnosis will be the highest priority?

Imbalanced nutrition, less than body requirements While any of the nursing diagnoses could apply to the situation, Imbalanced nutrition, less than body requirements would be the highest priority based on the criteria listed. The 5-year mortality rate for anorexia nervosa is 15% to 20% based on the physiological complications that occur.

A nurse is caring for a newborn with a repaired cleft lip. What intervention can the nurse provide to facilitate drainage of mucus and secretions to prevent aspiration?

Position the child on the side. To facilitate drainage of mucus and secretions, the nurse should position the infant on the side, never on the abdomen, after a cleft lip repair.

A nurse is assessing a 3-year-old child for possible bacterial meningitis. Which sign would indicate irritation of the meninges?

Positive Kernig sign A positive Kernig sign can indicate irritation of the meninges. A positive Brudzinski sign also is indicative of the condition. A positive Chadwick sign is a bluish discoloration of the cervix indicating pregnancy

The nurse is conducting a prenatal class explaining the various activities which will occur within the first 4 hours after birth. The nurse determines the session is successful when the couples correctly choose which reason for the use of an antibiotic ointment? Protect the urethra from fecal material Prevent infection of the umbilical cord Protect tear ducts from vaginal bacteria Prevent infection of the eyes from vaginal bacteria

Prevent infection of the eyes from vaginal bacteria Antibiotic ointment is used in the infant's eyes at birth to prevent ophthalmia neonatorum, an infection which can lead to blindness. It is not an acceptable practice to apply antibiotic ointment to the tear ducts, the umbilical cord, or the perineum and urethra.

An infant is suspected of having persistent pulmonary hypertension of the newborn (PPHM). What intervention implemented by the nurse would be most beneficial in treating this client?

Provide oxygen by oxygen hood or ventilator. The nurse should administer oxygen to the infant in whatever manner needed to help maintain the infant's oxygen levels. Anticonvulsants are not necessary in treating this disorder. The infant's physical environment should be warm, not cool, and stimulation should be limited for these clients.

A nurse is teaching newborn care to students. The nurse correctly identifies which of the following as the predominant form of heat loss in the newborn? a) Nonshivering thermogenesis. b) Sweating and peripheral vasoconstriction. c) Radiation, convection, and conduction. d) Lack of brown adipose tissue.

Radiation, convection, and conduction. Correct Explanation: Heat loss in the newborn occurs primarily through radiation, convection, and conduction because of the newborn's large ratio of body surface to weight, and because of the marked difference between core and skin temperatures. Nonshivering thermogenesis is a mechanism of heat production in the newborn. Lack of brown adipose tissue contributes to heat loss, particularly in premature infants, but it is not the predominant form of heat loss. Peripheral vasoconstriction is a method to increase heat production.

The nurse is documenting assessment of infant reflexes. She strokes the side of the infants face and the baby turns toward the stroke. What reflex has the nurse elicited? a) Moro b) Tonic neck c) Sucking d) Rooting

Rooting Correct Explanation: This is the rooting reflex and is used to encourage the infant to feed. This reflex and the sucking reflex work together to assist the infant with cues for feeding at the breast. The tonic neck (or fencing) reflex and the Moro (or startle reflex) are total body reflexes and assess neurologic function in the newborn.

A newborn with newly diagnosed hemolytic jaundice is being treated with phototherapy. Which actions should the nurse take? Select all that apply.

Shield the newborn's genitals and eyes during phototherapy sessions. Encourage the mother to breastfeed (8 to 12 feedings per day). Supplement breast milk with formula. Expose as much of the newborn's skin as possible. For the newborn receiving phototherapy, place the newborn under the lights or on the fiber-optic blanket, exposing as much skin as possible. Cover the newborn's genitals and shield the eyes to protect these areas from becoming irritated or burned when using direct lights. Assess the intensity of the light source to prevent burns and excoriation. Turn the newborn every 2 hours to maximize the area of exposure, removing the newborn from the lights only for feedings. Maintain a neutral thermal environment to decrease energy expenditure, and assess the newborn's neurologic status frequently. Research is finding that intermittent versus continuous phototherapy is as efficacious to lower bilirubin levels. Assess the newborn's temperature every 3 to 4 hours as indicated. Monitor fluid intake and output closely.

Which nursing assessment data should be given the highest priority for a child with clinical findings related to meningitis?

Signs of increased intracranial pressure (ICP) Assessment of fever and evaluation of nuchal rigidity are important aspects of care, but assessment for signs of increasing ICP should be the highest priority due to the life-threatening implications. Urinary and fecal incontinence can occur in a child who's ill from nearly any cause but doesn't pose a great danger to life

After a difficult birth, the nurse observes that a newborn has swelling on part of his head. The nurse suspects caput succedaneum based on what evidence?

The swelling crosses the midline of the infant's scalp. The fact that the swelling crosses the midline of the infant's scalp indicates caput succedaneum. If the swelling is limited and does not cross the midline or suture lines, it would suggest cephalohematoma. Low birthweight does not suggest caput succedaneum. Low-set ears may be seen in infants with chromosomal abnormalities. Facial abnormalities may accompany encephalocele

The newborn should have the neurologic status evaluated to determine its maturity and to identify any potential problems. The nurse tests the newborn's Babinski reflex. Which response would the nurse interpret as normal for the newborn? Infant throws arms outward and flexes knees. Infant's toes curl over the nurse's finger. Infant makes stepping motion. Toes fan out when sole of foot is stroked.

Toes fan out when sole of foot is stroked. The Babinski reflex is elicited by stroking the lateral sole of the newborn's foot from the heel toward and across the ball of the foot. The toes should fan out. The Moro reflex occurs when the infant is startled and will respond by throwing the arms outward and flexing the knees. The stepping reflex should elicit a stepping motion or walking when held upright. The plantar grasp will occur when a finger is placed just below the newborn's toes and the toes typically curl over the finger.

A first-time mother informs the nurse that she is unable to breastfeed her newborn through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for her newborn to have later. What instruction would be correct to offer the mother to ensure the safety of the stored expressed breast milk? Use any frozen milk within 6 months of obtaining it. Use the sealed and chilled milk within 24 hours. Use microwave ovens to warm the chilled milk. Refreeze any unused milk for later use if it has not been out more that 2 hours.

Use the sealed and chilled milk within 24 hours. The nurse should instruct the woman to use the sealed and chilled milk within 24 hours. The nurse should not instruct the woman to use frozen milk within 6 months of obtaining it, to use microwave ovens to warm chilled milk, or to refreeze the used milk and reuse it. Instead, the nurse should instruct the woman to use frozen milk within 3 months of obtaining it, to avoid using microwave ovens to warm chilled milk, and to discard any used milk and never refreeze it.

The parents of a 1-day-old newborn are concerned the infant is cold and shivering. Which action should the nurse prioritize to best prevent heat loss? Cover the newborn with several blankets while under the warmer. Warm all surfaces and objects that come in contact with the newborn. Keep the newborn under the radiant heater when not with mom. Bathe and wash the newborn when temperature is 97.5° F (36.4° C)

Warm all surfaces and objects that come in contact with the newborn. The 1-day-old infant will have regulated body temperature at this point in life and the radiant heater is no longer used. Interventions are the best way to prevent heat loss for this newborn; these would include making sure surfaces such as scales, examination tables and instruments are warm. Keeping the newborn under a radiant heater and covering the newborn with several blankets while under the warmer could lead to hyperthermia, which can be just as detrimental to the newborn as hypothermia. Infants are bathed when their temperatures are stable.

The nurse is preparing to assess the pulse on a newborn who has just arrived to the nursery after being cleaned in the labor and birth suite and swaddled in a blanket. Which action should the nurse prioritize? Clean hands with a betadine scrub. Perform a 3-minute surgical-type scrub. Use infection transmission precautions. Wear clean gloves.

Wear clean gloves. Infection control is a priority nursing intervention. Gloves need to be worn when in contact with the infant who has not been bathed after birth. All options are valid options; however, a three-minute surgical scrub is generally only required at the beginning of a shift. The nurse should always wash the hands before putting on gloves to care for an infant and after taking gloves off. Standard precautions are used with every client.

The nurse is caring for a newborn of a substance-abusing mother who is withdrawing from alcohol. Which finding would the nurse likely see in this newborn?

hyperactive and irritable The newborn that is withdrawing from alcohol typically is hyperactive, irritable, has trouble sleeping, and may have tremors or seizures. Characteristics of FAS include low birth weight, and small height and head circumference. This newborn is prone to respiratory difficulties, hypoglycemia, hypocalcemia, and hyperbilirubinemia.

Seven-year-old Isabelle has been complaining of headache, coughing, and an aching chest. The care provider makes a diagnosis of a viral infection. The child's mother tells the nurse that when Isabelle first said she had a headache, the child's father gave her half of an adult aspirin. The mother has heard of Reye syndrome and asks the nurse if her child could get this. Which statement would be best for the nurse to say to this mother?

"This might or might not be a problem. Watch Isabelle for signs of lethargy, unusual irritability, confusion, or vomiting. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome." Reye syndrome usually occurs after a viral illness, particularly after an upper respiratory infection or varicella (chickenpox). Administration of aspirin during the viral illness has been implicated as a contributing factor. As a result, the American Academy of Pediatrics recommends that aspirin or aspirin compounds not be given to children with viral infections. The symptoms appear within three to five days after the initial illness: The child is recuperating unremarkably when symptoms of severe vomiting, irritability, lethargy, and confusion occur. Immediate intervention is needed to prevent serious insult to the brain including respiratory arrest.

The nurse is caring for a newborn client newly diagnosed with dysplasia of the hip. Which response by the nurse educates the parents on the correct plan of treatment for this diagnosis?

"Treatment will begin immediately." Dysplasia of the hip is a congenital newborn condition that requires immediate intervention. The development of the acetabulum of the hip is defective, and it may or may not be dislocated. Treatment of the defect and dislocated hips involves positioning the hip into a flexed, abducted (externally rotated) position to attempt to press the femur into the acetabulum. This involves splints and halters as the first line of treatment. Treatment should not be delayed. Surgery and casts are typically not used as the first line of treatment.

The nurse is educating the family of a 7-year-old with epilepsy about care and safety for this child. What comment will be most valuable in helping the parent and the child cope?

"Use this information to teach family and friends." Families need and want information they can share with relatives, childcare providers, and teachers. Wearing a helmet and having a monitor in the room are precautions that may need to be modified as the child matures. The boy may be able to bike ride and swim with proper precautions.

A newborn boy is diagnosed with esophageal atresia and tracheoesophageal fistula. After the nurse provides preoperative teaching, which statement indicates that the parents need additional teaching?

"We can probably start feeding him with the bottle about a day after the surgery." Preoperatively, the newborn is at risk for pneumonitis due to aspiration of food and secretions. Antibiotics are typically given until the anastomosis is proven intact and patent. Oral feedings are usually started within a week after surgery once the esophageal anastomosis is proven to be intact and patent. Proper position with elevation of the head is important for the newborn with esophageal atresia and tracheoesophageal fistula because he is at risk for aspiration of food and secretions. Using a pacifier to provide nonnutritive sucking helps to meet the newborn's need to suck.

New parents are getting ready to go home and have received information to help them learn how best to care for the new infant. Which statement indicates that they need additional teaching about how to soothe their newborn if he becomes upset? "We'll turn the mobile on that's hanging above his head in his crib." "We'll lightly rub his back as we talk to him softly." "We'll swaddle him snuggly to make him feel secure." "We'll hold off on feeding him for a while because he might be too full."

"We'll hold off on feeding him for a while because he might be too full." The parents need more teaching that feeding or burping can be helpful in relieving air or stomach gas. Turning on a mobile above the newborn's head is helpful in calming the newborn. The movement is distracting, and the music is comforting. The newborn's back should be rubbed lightly while the parents speak softly to him. Swaddling the newborn provides security and comfort.

19.After determining that a newborn is in need of resuscitation, which of the following would the nurse do first? A) Dry the newborn thoroughly B) Suction the airway C) Administer ventilations D) Give volume expanders

A) Dry the newborn thoroughly

The nurse is assessing a preterm newborn who is in the neonatal intensive care unit (NICU. for signs and symptoms of overstimulation. Which of the following would the nurse be least likely to assess? A) Increased respirations B) Flaying hands C) Periods of apnea D) Decreased heart rate

A) Increased respirations

When planning the care for an SGA newborn, which action would the nurse determine as a priority? A) Preventing hypoglycemia with early feedings B) Observing for respiratory distress syndrome C) Promoting bonding between the parents and the newborn D) Monitoring vital signs every 2 hours

A) Preventing hypoglycemia with early feedings

A nurse suspects that a preterm newborn is having problems with thermal regulation. Which of the following would support the nurses suspicion? (Select all that apply.) A) Shallow, slow respirations B) Cyanotic hands and feet C) Irritability D) Hypertonicity E) Feeble cry

A) Shallow, slow respirations B) Cyanotic hands and feet E) Feeble cry

23. A boy with leukemia screams whenever he needs to be turned or moved. Which is the most probable cause of this pain? a. Edema b. Bone involvement c. Petechial hemorrhages d. Changes within the muscles

ANS B: The invasion of the bone marrow with leukemic cells gradually causes a weakening of the bone and a tendency toward fractures. As leukemic cells invade the periosteum, increasing pressure causes severe pain. Edema, petechial hemorrhages, and changes within the muscles would not cause severe pain.

32. A young child with leukemia has anorexia and severe stomatitis. The nurse should suggest that the parents try which intervention? a. Relax any eating pressures. b. Firmly insist that child eat normally. c. Begin gavage feedings to supplement diet. d. Serve foods that are either hot or cold.

ANS: A A multifaceted approach is necessary for children with severe stomatitis and anorexia. First, the parents should relax eating pressures. The nurse should suggest that the parents try soft, bland foods; normal saline or bicarbonate mouthwashes; and local anesthetics. The stomatitis is a temporary condition. The child can resume good food habits as soon as the condition resolves.

18. In which of the conditions are all the formed elements of the blood simultaneously depressed? a. Aplastic anemia b. Sickle cell anemia c. Thalassemia major d. Iron deficiency anemia

ANS: A Aplastic anemia refers to a bone marrowfailure condition in which the formed elements of the blood are simultaneously depressed. Sickle cell anemia is a hemoglobinopathy in which normal adult hemoglobin is partly or completely replaced by abnormal sickle hemoglobin. Thalassemia major is a group of blood disorders characterized by deficiency in the production rate of specific hemoglobin globin chains. Iron deficiency anemia results in a decreased amount of circulating red cells.

38. The nurse is planning care for an adolescent with AIDS. Which is the priority nursing goal? a. Preventing infection b. Preventing secondary cancers c. Restoring immunologic defenses d. Identifying source of infection

ANS: A Because the child is immunocompromised in association with HIV infection, the prevention of infection is paramount. Although certain precautions are justified in limiting exposure to infection, these must be balanced with the concern for the childs normal developmental needs. Preventing secondary cancers is not currently possible. Current drug therapy is affecting the disease progression; although not a cure, these drugs can suppress viral replication, preventing further deterioration. Case finding is not a priority nursing goal.

4. The nurse is teaching parents about the importance of iron in a toddlers diet. Which explains why iron deficiency anemia is common during toddlerhood? a. Milk is a poor source of iron. b. Iron cannot be stored during fetal development. c. Fetal iron stores are depleted by age 1 month. d. Dietary iron cannot be started until age 12 months.

ANS: A Children between the ages of 12 and 36 months are at risk for anemia because cows milk is a major component of their diet and it is a poor source of iron. Iron is stored during fetal development, but the amount stored depends on maternal iron stores. Fetal iron stores are usually depleted by age 5 to 6 months. Dietary iron can be introduced by breastfeeding, iron-fortified formula, and cereals during the first 12 months of life.

30. The nurse is administering an IV chemotherapeutic agent to a child with leukemia. The child suddenly begins to wheeze and have severe urticaria. Which is the most appropriate nursing action? a. Stop drug infusion immediately. b. Recheck rate of drug infusion. c. Observe child closely for next 10 minutes. d. Explain to child that this is an expected side effect.

ANS: A If an allergic reaction is suspected, the drug should be immediately discontinued. Any drug in the line should be withdrawn, and a normal saline infusion begun to keep the line open. Rechecking the rate of drug infusion, observing the child closely for next 10 minutes, and explaining to the child that this is an expected side effect can all be done after the drug infusion is stopped and the child is evaluated.

40. The nurse is conducting a staff in-service on inherited childhood blood disorders. Which statement describes severe combined immunodeficiency syndrome (SCIDS)? a. There is a deficit in both the humoral and cellular immunity with this disease. b. Production of red blood cells is affected with this disease. c. Adult hemoglobin is replaced by abnormal hemoglobin in this disease. d. There is a deficiency of T and B lymphocyte production with this disease.

ANS: A Severe combined immunodeficiency syndrome (SCIDS) is a genetic disorder that results in deficits of both humoral and cellular immunity. Wiskott-Aldrich is an X-linked recessive disorder with selected deficiencies of T and B lymphocytes. Fanconi syndrome is a hereditary disorder of red cell production. Sickle cell disease is characterized by the replacement of adult hemoglobin with an abnormal hemoglobin S.

9. Parents of a child with sickle cell anemia ask the nurse, What happens to the hemoglobin in sickle cell anemia? Which statement by the nurse explains the disease process? a. Normal adult hemoglobin is replaced by abnormal hemoglobin. b. There is a lack of cellular hemoglobin being produced. c. There is a deficiency in the production of globulin chains. d. The size and depth of the hemoglobin are affected.

ANS: A Sickle cell anemia is one of a group of diseases collectively called hemoglobinopathies, in which normal adult hemoglobin is replaced by abnormal hemoglobin. Aplastic anemia is a lack of cellular elements being produced. Thalassemia major refers to a variety of inherited disorders characterized by deficiencies in production of certain globulin chains. Iron deficiency anemia affects the size and depth of the color.

4. The nurse is preparing to give oral care to a school-age child with mucositis secondary to chemotherapy administered to treat leukemia. Which preparations should the nurse use for oral care on this child? (Select all that apply.) a. Chlorhexidine gluconate (Peridex) b. Lemon glycerin swabs c. Antifungal troches (lozenges) d. Lip balm (Aquaphor) e. Hydrogen peroxide

ANS: A, C, D Preparations that may be used to prevent or treat mucositis include chlorhexidine gluconate (Peridex) because of its dual effectiveness against candidal and bacterial infections, antifungal troches (lozenges) or mouthwash, and lip balm (e.g., Aquaphor) to keep the lips moist. Agents that should not be used include lemon glycerin swabs (irritate eroded tissue and can decay teeth), hydrogen peroxide (delays healing by breaking down protein), and milk of magnesia (dries mucosa).

36. A young child with human immunodeficiency virus (HIV) is receiving several antiretroviral drugs. The purpose of these drugs is to: a. cure the disease. b. delay disease progression. c. prevent spread of disease. d. treat Pneumocystis carinii pneumonia.

ANS: B Although not a cure, these antiviral drugs can suppress viral replication, preventing further deterioration of the immune system and delaying disease progression. At this time, cure is not possible. These drugs do not prevent the spread of the disease. P. carinii prophylaxis is accomplished with antibiotics.

29. Which is often administered to prevent or control hemorrhage in a child with cancer? a. Nitrosoureas b. Platelets c. Whole blood d. Corticosteroids

ANS: B Most bleeding episodes can be prevented or controlled with the administration of platelet concentrate or platelet-rich plasma. Nitrosoureas, whole blood, and corticosteroids would not prevent or control hemorrhage.

15. The parents of a child hospitalized with sickle cell anemia tell the nurse that they are concerned about narcotic analgesics causing addiction. Which is appropriate for the nurse to explain about narcotic analgesics? a. Are often ordered but not usually needed b. Rarely cause addiction because they are medically indicated c. Are given as a last resort because of the threat of addiction d. Are used only if other measures, such as ice packs, are ineffective

ANS: B The pain of sickle cell anemia is best treated by a multidisciplinary approach. Mild to moderate pain can be controlled by ibuprofen and acetaminophen. When narcotics are indicated, they are titrated to effect and are given around the clock. Patient-controlled analgesia reinforces the patients role and responsibility in managing the pain and provides flexibility in dealing with pain. Few, if any, patients who receive opioids for severe pain become behaviorally addicted to the drug. Narcotics are often used because of the severe nature of the pain of vasoocclusive crisis. Ice is contraindicated because of its vasoconstrictive effects.

MULTIPLE RESPONSE 1. The nurse is planning care for a school-age child admitted to the hospital with hemophilia. Which interventions should the nurse plan to implement for this child? (Select all that apply.) a. Finger sticks for blood work instead of venipunctures b. Avoidance of IM injections c. Acetaminophen (Tylenol) for mild pain control d. Soft tooth brush for dental hygiene e. Administration of packed red blood cells

ANS: B, C, D Nurses should take special precautions when caring for a child with hemophilia to prevent the use of procedures that may cause bleeding, such as IM injections. The subcutaneous route is substituted for IM injections whenever possible. Venipunctures for blood samples are usually preferred for these children. There is usually less bleeding after the venipuncture than after finger or heel punctures. Neither aspirin nor any aspirincontaining compound should be used. Acetaminophen is a suitable aspirin substitute, especially for controlling mild pain. A soft toothbrush is recommended for dental hygiene to prevent bleeding from the gums. Packed red blood cells are not administered. The primary therapy for hemophilia is replacement of the missing clotting factor. The products available are factor VIII concentrates.

3. Which should the nurse teach about prevention of sickle cell crises to parents of a preschool child with sickle cell disease? (Select all that apply.) a. Limit fluids at bedtime. b. Notify the health care provider if a fever of 38.5 C (101.3 F) or greater occurs. c. Give penicillin as prescribed d. Use ice packs to decrease the discomfort of vasoocclusive pain in the legs. e. Notify the health care provider if your child begins to develop symptoms of a cold.

ANS: B, C, E The most important issues to teach the family of a child with sickle cell anemia are to (1) seek early intervention for problems, such as a fever of 38.5 C (101.3 F) or greater; (2) give penicillin as ordered; (3) recognize signs and symptoms of splenic sequestration, as well as respiratory problems that can lead to hypoxia; and (4) treat the child normally. The nurse emphasizes the importance of adequate hydration to prevent sickling and to delay the adhesionstasisthrombosisischemia cycle. It is not sufficient to advise parents to force fluids or encourage drinking. They need specific instructions on how many daily glasses or bottles of fluid are required. Many foods are also a source of fluid, particularly soups, flavored ice pops, ice cream, sherbet, gelatin, and puddings. Increased fluids combined with impaired kidney function result in the problem of enuresis. Parents who are unaware of this fact frequently use the usual measures to discourage bedwetting, such as limiting fluids at night. Enuresis is treated as a complication of the disease, such as joint pain or some other symptom, to alleviate parental pressure on the child. Ice should not be used during a vasoocclusive pain crisis because it vasoconstricts and impairs circulation even more.

5. The nurse is teaching parents of an infant about the causes of iron deficiency anemia. Which statement best describes iron deficiency anemia in infants? a. It is caused by depression of the hematopoietic system. b. It is easily diagnosed because of an infants emaciated appearance. c. Clinical manifestations are similar regardless of the cause of the anemia. d. Clinical manifestations result from a decreased intake of milk and the premature addition of solid foods.

ANS: C In iron deficiency anemia, the childs clinical appearance is a result of the anemia, not the underlying cause. Usually the hematopoietic system is not depressed in iron deficiency anemia. The bone marrow produces red cells that are smaller and contain less hemoglobin than normal red cells. Children who are iron deficient from drinking excessive quantities of milk are usually pale and overweight. They are receiving sufficient calories, but are deficient in essential nutrients. The clinical manifestations result from decreased intake of iron-fortified solid foods and an excessive intake of milk.

7. Iron dextran is ordered for a young child with severe iron deficiency anemia. Nursing considerations include to: a. administer with meals. b. administer between meals. c. inject deeply into a large muscle. d. massage injection site for 5 minutes after administration of drug.

ANS: C Iron dextran is a parenteral form of iron. When administered intramuscularly, it must be injected into a large muscle. Iron dextran is for intramuscular or intravenous (IV) administration. The site should not be massaged to prevent leakage, potential irritation, and staining of the skin.

22. Which is most descriptive of the pathophysiology of leukemia? a. Increased blood viscosity occurs. b. Thrombocytopenia (excessive destruction of platelets) occurs. c. Unrestricted proliferation of immature white blood cells (WBCs) occurs. d. First stage of coagulation process is abnormally stimulated.

ANS: C Leukemia is a group of malignant disorders of the bone marrow and lymphatic system. It is defined as an unrestricted proliferation of immature WBCs in the blood-forming tissues of the body. Increased blood viscosity may occur secondary to the increased number of WBCs. Thrombocytopenia may occur secondary to the overproduction of WBCs in the bone marrow. The coagulation process is unaffected by leukemia.

2. Several blood tests are ordered for a preschool child with severe anemia. The child is crying and upset because of memories of the venipuncture done at the clinic 2 days ago. The nurse should explain: a. venipuncture discomfort is very brief. b. only one venipuncture will be needed. c. topical application of local anesthetic can eliminate venipuncture pain. d. most blood tests on children require only a finger puncture because a small amount of blood is needed.

ANS: C Preschool children are concerned with both pain and the loss of blood. When preparing the child for venipuncture, the nurse will use a topical anesthetic to eliminate any pain. This is a traumatic experience for preschool children. They are concerned about their bodily integrity. A local anesthetic should be used, and a bandage should be applied to maintain bodily integrity. The nurse should not promise one attempt in case multiple attempts are required. Both finger punctures and venipunctures are traumatic for children. Both require preparation.

11. The nurse is conducting a staff in-service on sickle cell anemia. Which describes the pathologic changes of sickle cell anemia? a. Sickle-shaped cells carry excess oxygen. b. Sickle-shaped cells decrease blood viscosity. c. Increased red blood cell destruction occurs. d. Decreased adhesion of sickle-shaped cells occurs.

ANS: C The clinical features of sickle cell anemia are primarily the result of increased red blood cell destruction and obstruction caused by the sickle-shaped red blood cells. Sickled red cells have decreased oxygen-carrying capacity and transform into the sickle shape in conditions of low oxygen tension. When the sickle cells change shape, they increase the viscosity in the area where they are involved in the microcirculation. Increased adhesion and entanglement of cells occurs.

31. A school-age child with leukemia experienced severe nausea and vomiting when receiving chemotherapy for the first time. Which is the most appropriate nursing action to prevent or minimize these reactions with subsequent treatments? a. Encourage drinking large amounts of favorite fluids. b. Encourage child to take nothing by mouth (remain NPO) until nausea and vomiting subside. c. Administer an antiemetic before chemotherapy begins. d. Administer an antiemetic as soon as child has nausea.

ANS: C The most beneficial regimen to minimize nausea and vomiting associated with chemotherapy is to administer the antiemetic before the chemotherapy is begun. The goal is to prevent anticipatory symptoms. Drinking fluids will add to the discomfort of the nausea and vomiting. Remaining until nausea and vomiting subside will help with this episode, but the child will have the discomfort and be at risk for dehydration. Administering an antiemetic as soon as the child has nausea does not prevent anticipatory nausea.

6. Which should the nurse include when teaching the mother of a 9-month-old infant about administering liquid iron preparations? a. They should be given with meals. b. They should be stopped immediately if nausea and vomiting occur. c. Adequate dosage will turn the stools a tarry green color. d. Allow preparation to mix with saliva and bathe the teeth before swallowing.

ANS: C The nurse should prepare the mother for the anticipated change in the childs stools. If the iron dose is adequate, the stools will become a tarry green color. The lack of the color change may indicate insufficient iron. The iron should be given in two divided doses between meals when the presence of free hydrochloric acid is greatest. Iron is absorbed best in an acidic environment. Vomiting and diarrhea may occur with iron administration. If these occur, the iron should be given with meals, and the dosage reduced, then gradually increased as the child develops tolerance. Liquid preparations of iron stain the teeth. They should be administered through a straw and the mouth rinsed after administration.

12. Which clinical manifestation should the nurse expect when a child with sickle cell anemia experiences an acute vasoocclusive crisis? a. Circulatory collapse b. Cardiomegaly, systolic murmurs c. Hepatomegaly, intrahepatic cholestasis d. Painful swelling of hands and feet; painful joints

ANS: D A vasoocclusive crisis is characterized by severe pain in the area of involvement. If in the extremities, painful swelling of the hands and feet is seen; if in the abdomen, severe pain resembles that of acute surgical abdomen; and if in the head, stroke and visual disturbances occur. Circulatory collapse results from sequestration crises. Cardiomegaly, systolic murmurs, hepatomegaly, and intrahepatic cholestasis result from chronic vasoocclusive phenomena.

33. The nurse is preparing a child for possible alopecia from chemotherapy. Which should be included? a. Explain to child that hair usually regrows in 1 year. b. Advise child to expose head to sunlight to minimize alopecia. c. Explain to child that wearing a hat or scarf is preferable to wearing a wig. d. Explain to child that when hair regrows, it may have a slightly different color or texture.

ANS: D Alopecia is a side effect of certain chemotherapeutic agents. When the hair regrows, it may be a different color or texture. The hair usually grows back within 3 to 6 months after cessation of treatment. The head should be protected from sunlight to avoid sunburn. Children should choose the head covering they prefer.

8. The nurse is recommending how to prevent iron deficiency anemia in a healthy, term, breast-fed infant. Which should be suggested? a. Iron (ferrous sulfate) drops after age 1 month b. Iron-fortified commercial formula by age 4 to 6 months c. Iron-fortified infant cereal by age 2 months d. Iron-fortified infant cereal by age 4 to 6 months

ANS: D Breast milk supplies inadequate iron for growth and development after age 5 months. Supplementation is necessary at this time. The mother can supplement the breastfeeding with iron-fortified infant cereal. Iron supplementation or the introduction of solid foods in a breast-fed baby is not indicated. Providing iron-fortified commercial formula by age 4 to 6 months should be done only if the mother is choosing to discontinue breastfeeding.

25. A child with leukemia is receiving triple intrathecal chemotherapy consisting of methotrexate, cytarabine, and hydrocortisone. The purpose of this is to prevent: a. infection. b. brain tumor. c. drug side effects. d. central nervous system (CNS) disease.

ANS: D For certain children, CNS prophylactic therapy is indicated. This drug regimen is used to prevent CNS leukemia and will not prevent infection or drug side effects. If the child has a brain tumor in addition to leukemia, additional therapy would be indicated.

44. The nurse is reviewing first aid with a group of school nurses. Which statement made by a participant indicates a correct understanding of the information? a. If a child loses a tooth due to injury, I should place the tooth in warm milk. b. If a child has recurrent abdominal pain, I should send him or her back to class until the end of the day. c. If a child has a chemical burn to the eye, I should irrigate the eye with normal saline. d. If a child has a nosebleed, I should have the child sit up and lean forward.

ANS: D If a child has a nosebleed, the child should lean forward, not lie down. A tooth should be placed in cold milk or saliva for transporting to a dentist. Recurrent abdominal pain is a physiologic problem and requires further evaluation. If a chemical burn occurs in the eye, the eye should be irrigated with water for 20 minutes.

41. Several complications can occur when a child receives a blood transfusion. Which is an immediate sign or symptom of an air embolus? a. Chills and shaking b. Nausea and vomiting c. Irregular heart rate d. Sudden difficulty in breathing

ANS: D Signs of air embolism are sudden difficulty breathing, sharp pain in the chest, and apprehension. Air emboli should be avoided by carefully flushing all tubing of air before connecting to patient. Chills, shaking, nausea, and vomiting are associated with hemolytic reactions. Irregular heart rate is associated with electrolyte disturbances and hypothermia.

The nurse is assessing a newborn and notes a low nasal bridge with short upturned nose, flattened midface, and a long philtrum with narrow upper lip. What does the nurse suspect to find in the mother's history?

Alcohol use These are typical facial features of a child with fetal alcohol syndrome from alcohol use of the mother while pregnant.

A newborn at 33 weeks' gestation has an Apgar score of 5 at 10 minutes of life. Which nursing action is a priority?

Begin resuscitation measures. Determine the Apgar score at 1 and 5 minutes; if less than 7 at 5 minutes, repeat the assessment at 10 minutes of age. If the initial assessment is poor, begin resuscitation measures until the Apgar score is above 7. The Ballard score would not be performed at this time. Reviewing the L & D records or repeating the Apgar are not priorities.

A newborn is challenged to maintain an adequate body temperature. If a baby is placed too close to a cold air vent, the nurse can assume that the infant will lose heat by which mechanism? a) Conduction b) Convection c) Radiation d) None. This will not cause the infant to lose body heat.

Convection Correct Explanation: There are 4 main ways that a newborn loses heat, Convection is one of the four and occurs when cold air blows over the body of the infant resulting in a cooling to the infant. Conductive heat loss occurs when the newborn's skin touches a cold surface, causing body heat to transfer to the colder object. Heat loss occurs by radiation to a cold object that is close to, but not touching, the newborn. Evaporative heat loss happens when the newborn's skin is wet. As the moisture evaporates from the body surface, the newborn loses body heat along with the moisture. Option D is incorrect as the cold air blowing on the infant's skin will cause heat loss.

The nurse is discussing with a parent the difference between a breath-holding spell and a seizure. The nurse would be correct in telling the parent what information in regard to seizures?

Convulsive activity occurs. During seizures convulsive activity is typically noted. During a breath-holding spell, the child is bradycardiac, cyanosis occurs at the onset, and the EEG is normal.

The nurse is conducting a safety class for a group of new parents in the hospital. What tips would the nurse provide for these parents? Select all that apply. Do not remove the identification bands until the newborn is discharged from the hospital. Don't leave the newborn unattended unless the mother is going to the bathroom. Question anyone who is not wearing proper identification even if they are dressed in hospital attire. It is ok to release your newborn to hospital personnel when they come into your room to transport the newborn back to the nursery. Know when the newborn is scheduled for any tests and how long the procedure will last.

Do not remove the identification bands until the newborn is discharged from the hospital. Question anyone who is not wearing proper identification even if they are dressed in hospital attire. Know when the newborn is scheduled for any tests and how long the procedure will last. To ensure the safety of their newborn, parents must understand how to keep their infant safe. They are to never leave their newborn unattended at any time, be sure to ask to see identification of anyone who comes into the room to remove the infant, don't remove the newborn's identification bands until leaving the hospital at discharge, and know when any test or procedures are scheduled for their newborn. Parents are instructed to question anyone who does not have proper identification or acts suspiciously.

The mother of an 8-year-old boy is concerned that her son has attention-deficit/hyperactivity disorder. She describes the symptoms he demonstrates. Which behavior should the nurse recognize as an example of impulsiveness?

Jumping out of his seat in the middle of class and running to the bathroom without the teacher's permission The disorder is characterized by three major behaviors: inattention, impulsiveness, and hyperactivity. Inattention makes children become easily distracted and often may not seem to listen or complete tasks effectively. Impulsiveness causes them to act before they think and therefore to have difficulty with such tasks as awaiting turns. With hyperactivity, children may shift excessively from one activity to another, exhibit excessive or exaggerated muscular activity, such as excessive climbing onto objects, constant fidgeting, or aimless or haphazard running. Repeating words or phrases spoken by others is echolalia and is associated with autistic spectrum disorder.

A nurse is required to obtain the temperature of a healthy newborn who was placed in an open crib. Which is the most appropriate method for measuring a newborn's temperature? Tape electronic thermistor probe to the abdominal skin. Obtain the temperature rectally. Obtain the temperature orally. Place electronic temperature probe in the midaxillary area.

Place electronic temperature probe in the midaxillary area. The nurse should obtain a newborn's temperature by placing an electronic temperature probe in the midaxillary area. The nurse should not tape an electronic thermistor probe to the abdominal skin, as this method is applied only when the newborn is placed under a radiant heat source. Rectal temperatures are no longer taken because of the risk of perforation. Oral temperature readings are not taken for newborns.

A nurse is caring for a newborn client after birth who is diagnosed with myelomeningocele. Which nursing intervention would protect the newborn from injury?

Place the newborn in a prone or lateral position. The nurse should place the newborn in a prone or lateral position to keep pressure off the spinal sac and avoid newborn injury. Parents should be allowed to hold the stable infant with assistance. The spinal sac should be kept covered and moist until surgery to avoid rupture. Collecting urine decreases the risk of urine stasis, which is sometimes common in spinal defects

At birth there are multiple changes in the cardiac and respiratory systems. Which of the following is one of the changes to occur at birth in the cardiovascular system? a) Oxygen is exchanged in the lungs b) Fluid is removed from the alveoli and replaced with air c) Pressure changes occur and result in closure of the ductus arteriosus d) The oxygen in the blood decreases

Pressure changes occur and result in closure of the ductus arteriosus Correct Explanation: The ductus arteriosus is one of the openings through which there was fetal circulation. At birth, or within the first few days, this closes and the heart becomes the source of movement of blood to and from the lungs. The exchange of oxygen in the lungs is not a function of the cardiovascular system; it is a function of the respiratory system. Again, the removal of fluid from the alveoli is not a function of the cardiovascular system. The oxygen content of the blood increases; it does not decrease. Therefore options A, B and D are incorrect.

A nurse is assigned to care for a newborn with esophageal atresia. What preoperative nursing care is the priority for this newborn?

Prevent aspiration by elevating the head of the bed, and insert an NG tube to low suction. The preoperative nursing care focuses on preventing aspiration by elevating the head of the bed and insertion of an NG tube to low suction to prevent aspiration. Documenting the amount and color of drainage is not needed with the NG tube in place. An infant with esophageal atresia is NPO and fed nothing until after repairing the defect. Administering antibiotics and total parenteral nutrition is a postoperative nursing intervention when caring for a newborn with esophageal atresia.

The nurse on a pediatric mental health unit notices one of the clients continually avoids joining the other clients in the dining room for meals. The nurse is aware that the client is demonstrating characteristics of which disorder?

Social phobia Social phobia is a disorder characterized by the child or teen demonstrating a persistent fear of speaking or eating in front of others, using public restrooms, or speaking to authorities. Generalized anxiety disorder (GAD) is characterized by unrealistic concerns over past behavior, future events, and personal competence. Selective mutism refers to a persistent failure to speak. With separation anxiety the child may need to remain close to the parents, and the child's worries focus on separation themes.

A nurse is teaching a new mother about what to expect for bowel elimination in her newborn. Because the mother is breast-feeding, the nurse should tell her which of the following? a) Stools should be yellow-gold, loose, and stringy to pasty. b) Stools should be yellow-green and loose. c) Stools should be greenish and formed in consistency. d) Stools should be brown and loose.

Stools should be yellow-gold, loose, and stringy to pasty. Correct Explanation: The stools of a breast-fed newborn are yellow-gold, loose, and stringy to pasty in consistency. The stools of the formula-fed newborn vary depending on the type of formula ingested. They may be yellow, yellow-green, or greenish and loose, pasty, or formed in consistency, and they have an unpleasant odor.

A 9-year-old boy is suffering from headaches but has no signs of physical or neurologic illness. Which intervention would be most appropriate?

Teach the child and his parents to keep a headache diary. A headache diary can help identify any triggers so that the child can avoid them. Triggers can include foods eaten, amount of sleep the night before, or activities at home or school that might be causing stress. Reviewing signs of increased intracranial pressure would be inappropriate because increased intracranial pressure is not associated with headaches. Having the child sleep without a pillow is an intervention to reduce pain from meningitis. Vomiting more than twice is an indication that the parents should notify the physician or nurse practitioner when the child has a head injury.

Why should a nurse monitor a newborn after cesarean birth more closely than after a vaginal birth? a) The baby will have more fluid in its lungs, making respiratory adaptation more challenging. b) Fetal lungs are uninflated and full of amniotic fluid that must be absorbed. c) Much of the fetal lung fluid is squeezed out as the fetus moves down the birth canal. d) The baby's lifeline to oxygen is cut off when the umbilical cord is clamped, resulting in oxygen levels falling and carbon dioxide rising.

The baby will have more fluid in its lungs, making respiratory adaptation more challenging. Correct Explanation: During a vaginal delivery the infant is squeezed by the uterine contractions. The infant who is born via c-section without labor first does not have the mechanical removal of the fluid from the lungs. This places the infant at increased risk for respiratory compromise. The need to more closely assess a newborn after delivery by cesarean section is not caused by the clamping of the umbilical cord. Amniotic fluid in the lungs of all newborns needs to be absorbed by the body. This is not just a need in an infant born by cesarean section.

The nurse is reinforcing discharge teaching with the mother of an infant who is being discharged prior to having a required blood test done. The nurse explains to this mother that she needs to bring the newborn back to check the infant's phenylalanine level. Which statement is most accurate related to this blood test?

The test is done after the newborn has ingested protein. As soon as the newborn with phenylketonuria begins to take milk, phenylalanine builds up in the blood serum to as much as 20 times the normal level. This build-up occurs so quickly that increased levels of phenylalanine appear in the blood after only one or two days of ingestion of milk.

What objective data gathered by the nurse could indicate a diagnosis of developmental dysplasia of the hip? Select all that apply.

asymmetry of the gluteal skin folds limited abduction of the affected hip apparent shortening of the femur Signs that are useful after age 1 month are asymmetry of the gluteal skin folds, limited abduction of the affected hip, and apparent shortening of the femur.

The nurse is caring for a newborn who was small for gestational age and has been determined to have the condition intrauterine growth restriction (IUGR). It is most likely that the mother of this newborn:

has a history of abnormal blood glucose levels. Uncontrolled maternal diabetes can be a contributing factor for the infant with intrauterine growth restriction. Smoking during pregnancy could be a contributing factor, but being a previous smoker would not affect this pregnancy. Inadequate maternal nutrition is a contributing factor, but because this mother was on a food stamp program she was more likely to have had adequate nutrition during pregnancy. Previous pregnancies with a history of IUGR or other poor pregnancy outcomes would be a possible contributing factor, but not normal pregnancies.

A nurse is assigned to care for a high-risk newborn with a periventricular-intraventricular hemorrhage (PVH-IVH) in the home environment after discharge. For which condition should the nurse monitor the infant?

hydrocephalus A significant number of newborns with PVH-INH will incur brain injury, leading to complications that may include hydrocephalus. The nurse should monitor for the incidence of hydrocephalus in this high-risk newborn. Urinary tract infection is not condition that persists after discharge. Spina bifida is most often noted at birth and would not to need to be assessed for by the nurse. Formula intolerance is not specific to high-risk newborns.

A newborn is found to have hemolytic disease. Which combination would be found related to the blood types of this newborn and the parents of the newborn?

newborn who is type A, mother who is type O Hemolytic disease today is principally the result of ABO incompatibility. The most common incompatibility in the newborn occurs between a woman with type O blood and an infant with type A or B blood.