Fetal Alcohol Syndrome, Neonatal Abstinence Syndrome, Abusive Head trauma NCLEX

A father calls emergency medical services (EMS) for his 1-year-old infant who was vomiting and then experienced a series of seizures. Upon admission to the hospital, the infant was listless and irritable, had bradycardia, and had periods of apnea. The infant has now lapsed into a coma. Which of the following conditions will the nurse and the health care team members suspect and most want to rule out? a. spinal meningitis c. fever-induced seizures b. encephalitis d. shaken baby syndrome (SBS)

ANS: D Feedback A Incorrect: These manifestations are similar to those seen in spinal meningitis, but the health care team members would be most concerned and want to rule out SBS. The infant is at risk for additional injuries (death) from shaking if abuse has occurred. One-third of children with SBS die from their injuries; and one-third experience permanent injury. B Incorrect: Some of these manifestations also occur in encephalitis. However, health care team members would be most concerned and want to rule out SBS. The infant is at risk for additional injuries (death) from shaking if abuse has occurred. C Incorrect: Fever-induced seizures are brief, clonic, or tonic, clonic in nature. The other manifestations in this situation would not be evident with fever-induced seizures. D Correct: Infants should be suspected of SBS with any signs of head injury, including poor feeding or vomiting, irritability, listlessness, lethargy, bradycardia, apnea, seizures coma, bulging fontanels, large head circumference, hypothermia, or failure to thrive. The classic triad of SBS is hematoma, brain edema and retinal hemorrhages, usually bilateral.

Typical signs of abusive head trauma (Shaken Baby Syndrome) include which of the following? (SATA) a. Broken clavicle b. Poor feeding c. Vomiting d. Breathing problems

ANS: b, c, d Symptoms of abusive head trauma are extreme irritability, breathing problems, convulsions, vomiting, and pale or bluish skin.

Incidental ingestion can lead to injury. How can a parent of a toddler prevent his/her child from ingestion injury? 1. Clean up any old, chipping paint in the windowsills. 2. Buy products with childproof tops. 3. Keep all medication and poisonous products in high places or in a locked cabinet. 4. All of the above

ANS: 4 . 4. Paint chips can have lead and present a choking hazard. Childproof tops will prevent easy access to hazardous materials. Keeping medication and poisonous products locked will prevent children from having access.

What does the nursing care for infants with fetal alcohol syndrome (FAS) include? a. Nutritional guidance b. An intensive stimulation program c. Facilitation of improvement in cardiovascular status d. An individualized program based on maternal alcohol consumption

ANS: A Infants with FAS have characteristic poor feeding behaviors that persist throughout childhood. The nurse assists in devising strategies to improve nutrition. The infant is protected from overstimulation. FAS does not include cardiovascular problems. The effects of FAS do not depend on the quantity of maternal alcohol consumption.

A pregnant woman presents in labor at term, having had no prenatal care. After birth her infant is noted to be small for gestational age with small eyes and a thin upper lip. The infant also is microcephalic. On the basis of her infant's physical findings, this woman should be questioned about her use of which substance during pregnancy? a. Alcohol b. Cocaine c. Heroin d. Marijuana

ANS: A The description of the infant suggests fetal alcohol syndrome, which is consistent with maternal alcohol consumption during pregnancy. Fetal brain, kidney, and urogenital system malformations have been associated with maternal cocaine ingestions. Heroin use in pregnancy frequently results in intrauterine growth restriction. The infant may have a shrill cry and sleep cycle disturbances and present with poor feeding, tachypnea, vomiting, diarrhea, hypothermia or hyperthermia, and sweating. Studies have found a higher incidence of meconium staining in infants born of mothers who used marijuana during pregnancy.

A nurse is caring for four patients in the pediatric intensive care unit with head injuries or brain infections. Which child should the nurse see first? A. Blood pressure change from 110/58 to 134/40 mm Hg in a child with brain injury B. Child with brain injury who has vomited twice in 12 hours, now sleeping C. Child with meningitis who is irritable, complaining of a "bad" headache D. Oral temperature of 100.4°F (38°C) in a child with meningitis

ANS: A Hypertension (with widening pulse pressure), bradycardia, and changes in respiratory pattern are components of Cushing's triad, a late sign of increased intracranial pressure, indicative of impending herniation. The change in the child's blood pressure, including the widened pulse pressure (difference between systolic and diastolic pressures), is worrisome. A child with a head injury and minimal vomiting is not alarming. A child with a brain infection who is irritable with a headache needs attention, but not over the child with possible herniation. An oral temperature of 100°F would be expected in a child with a brain infection.

The nurse is admitting a drug-exposed newborn to the neonatal intensive care unit. The nurse should assess the newborn for which signs of withdrawal? (SATA) a. Tremors b. Nasal stuffiness c. Loose, watery stools d. Hypoactive Moro reflex e. Decrease in respiratory rate

ANS: A, B, C Signs of withdrawal in a drug-exposed newborn include increased tone; increased respiratory rate; disturbed sleep; fever; excessive sucking; and loose, watery stools. Other signs observed included projectile vomiting, mottling, crying, nasal stuffiness, hyperactive Moro reflex, and tremors.

Many common drugs of abuse cause significant physiologic and behavioral problems in infants who are breastfed by mothers currently using (SATA) a. Amphetamine. b. Heroin. c. Nicotine. d. PCP. e. Morphine

ANS: A, B, C, D Amphetamine, heroin, nicotine, and PCP are contraindicated during breastfeeding because of the reported effects on the infant. Morphine is a medication that often is used to treat neonatal abstinence syndrome.

A nurse is caring for a baby with neonatal abstinence syndrome. Which of the following medications should the nurse be prepared to give? (SATA) A. Chlorpromazine (Thorazine) B. Clonidine (Catapres) C. Diazepam (Valium) D. Phenobarbital (Luminal) E. Naloxone (Narcan)

ANS: A, B, C, D Several medications are used to treat the infants of drug-abusing mothers, including paregoric (camphorated tincture of opium), phenobarbital (Luminal), clonidine (Catapres), chlorpromazine (Thorazine), and diazepam (Valium). Naloxone (Narcan) is not used because it can increase the severity of drug withdrawal in the infant.

A nurse is assessing a newborn for facial feature characteristics associated with fetal alcohol syndrome: Which characteristics should the nurse expect to assess? (SATA) a. Short palpebral fissures b. Smooth philtrum c. Low set ears d. Inner epicanthal folds e. Thin upper lip

ANS: A, B, E Feedback Correct Infants with fetal alcohol syndrome may have characteristic facial features, including short palpebral fissures, a smooth philtrum (the vertical groove in the median portion of the upper lip), and a thin upper lip. Incorrect Low set ears and inner epicanthal folds are associated with Down syndrome.

What are symptoms of abusive head trauma (AHT) in the more severe form that may be present? (SATA) a. Seizures b. Posturing c. Tachypnea d. Tachycardia e. Altered level of consciousness

ANS: A, B, E In more severe forms, presenting symptoms of abusive head trauma may include seizures, posturing, alterations in level of consciousness, apnea, bradycardia, or death.

What can the nurse suggest to families to reduce blood lead levels? (SATA) a. Do not store food in open cans. b. Ensure the child eats regular meals. c. Mix formula with hot water from the tap. d. Vacuum hard-surfaced floors and window wells. e. Wash and dry the child's hands and face frequently.

ANS: A, B, E To reduce blood lead levels, the family should ensure the child eats regular meals because more lead is absorbed on an empty stomach. The child's hands and face should be washed and dried frequently, especially before eating. Food should not be stored in open cans, particularly if cans are imported. Hot water dissolves lead more quickly than cold water and thus contains higher levels of lead. Hot water should not be used to mix formula. Hard-surfaced floors or window sills or wells should not be vacuumed because this spreads dust.

A nurse is caring for a 1-year-old child who was admitted for seizures. The parents ask what could have caused the child's seizure. The nurse explains that seizures can be caused by which problems? (SATA) A. Brain injury B. Central nervous system infection C. Hypertension D. Renal failure E. Unknown cause

ANS: A, B, E Seizures can be caused by many things, including traumatic brain injury, infection in the central nervous system, ingestion of toxins, endocrine dysfunction, atrial-venous malformation, or anoxia. The etiology may also be unknown.

What should be the nurse's first action when a child with a head injury complains of double vision and a headache and then vomits? a. Immobilize the child's neck. b. Report this information to the physician. c. Darken the room and put a cool cloth on the child's forehead. d. Restrict the child's oral fluid intake.

ANS: B Any indication of increased intracranial pressure should be promptly reported to the physician. Stabilizing the child's neck does not address the child's symptoms. Darkening the room and putting a cool cloth on the child's forehead may facilitate the child's comfort. It would not be the nurse's first action. The child's episode of vomiting does not necessitate a fluid restriction.

A child with a head injury sleeps unless aroused, and when aroused responds briefly before falling back to sleep. Which term corresponds to this child's level of consciousness? a. Disoriented b. Obtunded c. Lethargic d. Stuporous

ANS: B Obtunded describes an individual who sleeps unless aroused and once aroused has limited interaction with the environment. Disoriented refers to the lack of ability to recognize place or person. An individual is lethargic when he or she awakens easily but exhibits limited responsiveness. Stupor refers to requiring considerable stimulation to arouse the individual.

What is a significant secondary prevention nursing activity for lead poisoning? a. Chelation therapy b. Screening children for blood lead levels c. Removing lead-based paint from older homes d. Questioning parents about ethnic remedies containing lead

ANS: B Screening children for lead poisoning is an important secondary prevention activity. Screening does not prevent the initial exposure of the child to lead. It can lead to identification and treatment of children who are exposed. Chelation therapy is treatment, not prevention. Removing lead-based paints from older homes before children are affected is primary prevention. Questioning parents about ethnic remedies containing lead is part of the assessment to determine the potential source of lead.

A child has been admitted to the hospital with a blood lead level of 72 mcg/dL. What treatment should the nurse anticipate? a. Referral to social services b. Initiation of chelation therapy c. Follow-up testing within 1 month d. Aggressive environmental intervention

ANS: B Severe lead toxicity (lead level >5=70 mcg/dL) requires immediate inpatient chelation treatment. Referral to social service and follow-up in 1 month are prescribed for lead levels of 15 to 19 mcg/dL. Aggressive environmental intervention would be initiated after chelation treatments.

A 3-month-old infant dies shortly after arrival to the emergency department. The infant has subdural and retinal hemorrhages but no external signs of trauma. What should the nurse suspect? a. Unintentional injury b. Shaken baby syndrome c. Congenital neurologic problem d. Sudden infant death syndrome (SIDS)

ANS: B Shaken baby syndrome causes internal bleeding but may have no external signs. Unintentional injury would not cause these injuries. With unintentional injuries, external signs are usually present. Congenital neurologic problems would usually have signs of abnormal neurologic anatomy. SIDS does not usually have identifiable injuries.

Providing care for the neonate born to a mother who abuses substances can present a challenge for the health care team. Nursing care for this infant requires a multisystem approach. The first step in the provision of this care is: a. Pharmacologic treatment. b. Reduction of environmental stimuli. c. Neonatal abstinence syndrome scoring. d. Adequate nutrition and maintenance of fluid and electrolyte balance.

ANS: C Neonatal abstinence syndrome (NAS) is the term used to describe the cohort of symptoms associated with drug withdrawal in the neonate. The Neonatal Abstinence Scoring System evaluates central nervous system (CNS), metabolic, vasomotor, respiratory, and gastrointestinal disturbances. This evaluation tool enables the care team to develop an appropriate plan of care. The infant is scored throughout the length of stay, and the treatment plan is adjusted accordingly. Pharmacologic treatment is based on the severity of withdrawal symptoms. Symptoms are determined by using a standard assessment tool. Medications of choice are morphine, phenobarbital, diazepam, or diluted tincture of opium. Swaddling, holding, and reducing environmental stimuli are essential in providing care to the infant who is experiencing withdrawal. These nursing interventions are appropriate for the infant who displays CNS disturbances. Poor feeding is one of the gastrointestinal symptoms common to this client population. Fluid and electrolyte balance must be maintained and adequate nutrition provided. These infants often have a poor suck reflex and may need to be fed via gavage.

In caring for the mother who has abused (or is abusing) alcohol and for her infant, nurses should be aware that: a. The pattern of growth restriction of the fetus begun in prenatal life is halted after birth, and normal growth takes over. b. Two thirds of newborns with fetal alcohol syndrome (FAS) are boys. c. Alcohol-related neurodevelopmental disorders not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school. d. Both the distinctive facial features of the FAS infant and the diminished mental capacities tend toward normal over time.

ANS: C Some learning problems do not become evident until the child is at school. The pattern of growth restriction persists after birth. Two thirds of newborns with FAS are girls. Although the distinctive facial features of the FAS infant tend to become less evident, the mental capacities never become normal.

What is an important nursing consideration when a child is hospitalized for chelation therapy to treat lead poisoning? a. Maintain bed rest. b. Maintain isolation precautions. c. Keep an accurate record of intake and output. d. Institute measures to prevent skeletal fracture.

ANS: C The iron chelates are excreted though the kidneys. Adequate hydration is essential. Periodic measurement of renal function is done. Bed rest is not necessary. Often the chelation therapy is done on an outpatient basis. Chelation therapy is not infectious or dangerous. Isolation is not indicated. Skeletal weakness does not result from high levels of lead.

The nurse is caring for a child with severe head trauma after a car accident. Which is an ominous sign that often precedes death? a. Papilledema b. Delirium c. Doll's head maneuver d. Periodic and irregular breathing

ANS: D Periodic or irregular breathing is an ominous sign of brainstem (especially medullary) dysfunction that often precedes complete apnea. Papilledema is edema and inflammation of the optic nerve. It is commonly a sign of increased intracranial pressure. Delirium is a state of mental confusion and excitement marked by disorientation to time and place. The doll's head maneuver is a test for brainstem or oculomotor nerve dysfunction.

A 1-day-old neonate in the well-baby nursery is suspected of suffering from drug withdrawal because he is markedly hyperreflexic and is exhibiting which of the following additional sign or symptom? a. Prolonged periods of sleep b. Hypovolemic anemia c. Repeated bouts of diarrhea d. Pronounced pustular rash

ANS: c Feedback a. Babies who are withdrawing from drugs have disorganized behavioral states and sleep very poorly. b. There is nothing in the scenario that indicates that this child is hypovolemic or anemic. c. Babies who are experiencing withdrawal often experience bouts of diarrhea. d. A pustular rash is characteristic of an infectious problem, not of neonatal abstinence syndrome.

In planning care for the fetal alcohol syndrome (FAS) newborn, which intervention would the nurse include? 1. Allow extra time with feedings. 2. Assign different personnel to the newborn each day. 3. Place the newborn in a well-lit room. 4. Monitor for hyperthermia.

Answer: 1 Explanation: 1. Newborns with fetal alcohol syndrome have feeding problems. Because of their feeding problems, these infants require extra time and patience during feedings.

The nurse is caring for the newborn of a drug-addicted mother. Which assessment findings would be typical for this newborn? 1. Hyperirritability 2. Decreased muscle tone 3. Exaggerated reflexes 4. Low pitched cry 5. Transient tachypnea

Answer: 1, 3, 5 Explanation: 1. Newborns born to drug-addicted mothers exhibit hyperirritability. 3. Newborns born to drug-addicted mothers exhibit exaggerated reflexes. 5. Newborns born to drug-addicted mothers exhibit transient tachypnea.

During discharge planning for a drug-dependent newborn, the nurse explains to the mother how to do which of the following? 1. Place the newborn in a prone position. 2. Limit feedings to three a day to decrease diarrhea. 3. Place the infant supine and operate a home apnea-monitoring system. 4. Wean the newborn off the pacifier.

Answer: 3 Explanation: 3. Infants with neonatal abstinence syndrome are at a significantly higher risk for sudden infant death syndrome (SIDS) when the mother used heroin, cocaine, or opiates. The infant should sleep in a supine position, and home apnea monitoring should be implemented.

Parents have been told their child has fetal alcohol syndrome (FAS). Which statement by a parent indicates that additional teaching is required? 1. "Our baby's heart murmur is from this syndrome." 2. "He might be a fussy baby because of this." 3. "His face looks like it does due to this problem." 4. "Cuddling and rocking will help him stay calm."

Answer: 4 Explanation: 4. The FASD baby is most comfortable in a quiet, minimally stimulating environment.

The nurse teaches a group of parents strategies to reduce the risk of lead exposure for their children. Which statements indicate an appropriate understanding of the content presented? (SATA) 1. "We will provide our child with frequent snacks high in iron and calcium." 2. "We will wash any surfaces that have peeling paint." 3. "We will store leftovers in a ceramic pot." 4. "We can continue to use our traditional-medicine treatment, azarcon, for any GI upset." 5. "We will sand the windowsills to remove the lead-based paint."

Correct Answer: 1,2 Snacks and meals high in iron and calcium should be encouraged. Lead is absorbed more readily on an empty stomach. Any surface with peeling paint should be washed with a damp sponge. Ceramic pots, if fired improperly, could contain lead. Food should not be prepared or stored in them. Azarcon, a traditional medicine used to treat a coliclike illness, may contain large amounts of lead. Sanding the windowsills will cause the lead to be dispersed in the air, leading to lead poisoning.

A child diagnosed with a mild traumatic brain injury is being sedated with a mild sedative so that pain and anxiety are minimized. Which nursing interventions are appropriate for this child? (SATA) 1. Place a continuous-pulse oximetry monitor on the child. 2. Place the child in a room near the nurse's station. 3. Allow for several visitors to remain at the child's bedside. 4. Use soft restraints if the child becomes confused. 5. Use sedation around the clock to decrease agitation.

Correct Answer: 1,2 When a child is sedated, respiratory status should be monitored with a pulse-oximetry machine. The child should be close to the nurse's station so that frequent monitoring can be done. Several visitors at the bedside would increase the child's anxiety. Soft restraints may increase agitation. Sedation around the clock is not recommended due to the need to evaluate the neurologic system.

A child sustains a traumatic brain injury and is monitored in the pediatric intensive-care unit (PICU). The nurse is using the Glasgow Coma Scale to assess the child. Which items will the nurse assess when using this tool? Standard Text: (SATA) 1. Eye opening 2. Verbal response 3. Motor response 4. Head circumference 5. Pulse oximetry

Correct Answer: 1,2,3 The Glasgow Coma Scale for infants and children scores parameters related to eye opening, verbal response, and motor response. The maximum score is 15, indicating the highest level of neurological functioning. Head circumference and pulse oximetry are not included on the scale.

When examining a toddler-age child during a well-child physical, which assessment is the priority? 1. Visual acuity 2. Helmet use 3. Risk of lead exposure 4. Whether household drinking water contains fluorine

Correct Answer: 3 Elevated lead levels are neurotoxic to young children and, if untreated, can cause irreparable neurological damage. Visual acuity may be difficult to accurately assess at this age secondary to the child's compliance and ability to understand the directions for the screening test. While teaching helmet use at an early age is important, it is unlikely that this child is riding a bicycle yet, and although early exposure to fluorine is important for good dental health, lack of fluorinated drinking water will not be as harmful to the child as toxic lead levels.