Infant passp

A 5-month-old infant with an upper respiratory infection is brought to the clinic. The mother reports that the infant weighed 7 lb (3.2 kg) at birth. Based on the nurse's knowledge of infant weight gain, which current weight would be within the normal range for this infant?

14 lb (6.4 kg)

A mother is concerned that she might be spoiling her 2-month-old daughter by picking her up each time she cries. Which suggestion should the nurse offer?

"Continue to pick her up when she cries because young infants need cuddling and holding to meet their needs."

The nurse is teaching circumcision care to a mother before discharge. Which statement by the mother indicates that teaching was successful?

"I should reapply fresh petrolatum gauze after each diaper change."

A bottle-fed infant, age 3 months, is brought to the pediatrician's office for a well-child visit. During the previous visit, the nurse taught the mother about infant nutritional needs. Which statement by the mother during the current visit indicates effective teaching?

"I'm giving the baby iron-fortified formula and a fluoride supplement because our water isn't fluoridated."

A parent brings her 3-month-old to the clinic for a well-baby examination. Which statement by the parent should concern the nurse?

"She's eating rice cereal and applesauce

Which statement by a caregiver indicates that a 10 month old is at high risk for iron deficiency anemia?

"The baby drinks about five 8-oz bottles of milk per day."

After the birth of her first neonate, a mother asks the nurse about the reddened areas ("stork bites") at the nape of the neonate's neck. How should the nurse respond?

"They're normal and will disappear as the baby's skin thickens."

The nurse would explain to the parents of a newborn with a cleft lip and palate that they will need to schedule an appointment with which specialist?

Otolaryngologist

The nurse is caring for an infant who has undergone a surgical repair of a cleft lip. The health care provider prescribes elbow restraints. What nursing action should be included in the infant's plan of care?

Remove the restraints every 2 hours.

An 11-month-old infant with bronchopulmonary dysplasia and a tracheostomy experiences a decline in oxygen saturation from 97% to 88%. The infant appears anxious and the heart rate is 180 beats/minute. Which intervention is most appropriate?

Suction the tracheostomy tube.

The nurse is preparing the parents of an infant with hypospadias for surgery. Which statement made by the parents would indicate the need for further education?

"After surgery, my infant's penis will look perfectly normal."

An infant is brought to the emergency department and pronounced dead with the preliminary finding of sudden infant death syndrome (SIDS). Which question to the parents is most appropriate?

"How did the infant look when you found him?"

The nurse is teaching parents how to select appropriate toys for their 10-month-old infant. Which statement by the parents indicates effective teaching?

"We'll get a push toy for the baby."

A mother and grandmother bring a 3-month-old infant to the well-baby clinic for a routine checkup. As the nurse weighs the infant, the grandmother asks, "Shouldn't the baby start eating solid food? My kids started on cereal when they were 2 weeks old." Which response by the nurse would be appropriate?

"We've found that babies can't digest solid food properly until they're 4 months old."

The nurse is approached by the mother of a child with hypospadias. She says to the nurse, "Why did this have to happen to my baby? Why couldn't he be perfect? How could this have happened?" What should the nurse say in response?

"You seem upset. Tell me about it."

A client who has tested positive for the human immunodeficiency virus (HIV) gives birth to her baby. When she asks whether her baby has acquired immunodeficiency syndrome (AIDS), how should the nurse respond?

"Your baby may have acquired HIV in utero, but we won't know for sure until the baby is older."

An infant, diagnosed with bronchiolitis, is ordered a mist tent with oxygen. The parents question how a mist tent with oxygen can help their infant. The nurse is most correct to identify which? Select all that apply.

-assists in decreasing bronchial edema -assists in improving cough -assists in improving oxygen saturation

While checking a 2-month-old infant's airway, a nurse finds that the child is not breathing. After two unsuccessful attempts to rescue breathe, how should the nurse proceed?

Administer five back blows.

Before a routine checkup in the pediatrician's office, an 8-month-old infant sits contentedly on the mother's lap, chewing on a toy. When preparing to examine this infant, what should the nurse plan to do first?

Auscultate the heart and lungs.

The parent of a 6-month-old infant with atopic dermatitis asks for advice on bathing the child. Which instructions or information should the nurse give to the parent?

Bathe the infant every other day.

When performing cardiopulmonary resuscitation on a 7-month- old infant, which location would the nurse use to evaluate the presence of a pulse?

Brachial artery

A hospitalized infant, age 10 months, begins to choke while eating and quickly becomes unconscious. A foreign object isn't visible in the infant's airway, but respirations are absent and the pulse is 50 beats/minute and thready. The nurse attempts rescue breathing, but the ventilations are unsuccessful. What should the nurse do next?

Deliver five back blows.

The nurse is preparing for the discharge of a neonate with a cleft lip and palate. Which nursing instruction is of highest priority?

Establish a feeding technique

At a previous visit, the parents of an infant with cystic fibrosis received instruction in the administration of pancrelipase. At a follow-up visit, which finding suggests the need for further teaching?

Fatty stools

How should a nurse position an infant when administering an oral medication?

Held in the bottle- or breast-feeding position

A 10-month-old child is found choking and soon becomes unconscious. Which intervention should the nurse attempt first after opening the airway?

Look inside the infant's mouth for a foreign object.

The nurse is weighing a 3-month-old infant of Mediterranean descent during a routine examination in a family health center. The nurse documents the bluish discoloration of the skin on the lower back as which condition?

Mongolian spots

A recent abduction of a 2-month-old infant has raised awareness of the need for security plans for hospitals. Which security measure helps ensure the hospitalized infant's security?

Placing an identification bracelet on the infant and the parent immediately on admission

An infant has a positive test result for diabetes insipidus. The nurse should anticipate the health care provider will order a test dose of which medication?

aqueous vasopressin

Which plan is most appropriate for a discharge home visit to parents who lost an infant to sudden infant death syndrome (SIDS)?

as soon after death as possible

An 8-month-old infant has been diagnosed with developmental dysplasia of the hip (DDH). What is the most significant finding the nurse would expect in the perinatal history related to DDH?

breech presentation at birth

A 1-month-old infant is admitted to the pediatric unit and diagnosed with bacterial meningitis. Which findings by the nurse support the diagnosis?

fever, change in feeding pattern, vomiting, or diarrhea

The nurse is caring for an infant with hypospadias. Which anomaly would the nurse assess the infant for that commonly accompanies this condition?

indescended testes

Which complications should the nurse be most concerned about in the first 12 hours of life for a neonate born with a myelomeningocele?

infection

When collecting data on an infant, which condition would alert the nurse as a subtle sign of hypothyroidism?

lethargy

A nurse is observing an infant with thyroid hormone deficiency. Which signs would the nurse commonly observe?

lethargy, feeding difficulties, and constipation

A nurse is obtaining data on a newborn with a possible diagnosis of cystic fibrosis. Which sign does the nurse recognize as an early indicator of the disease?

meconium ileus

A healthy, 6-month-old infant is brought to the well-baby clinic for a checkup. When checking the infant's anterior fontanel the nurse expects it to be:

open.

The parents of a 6 month old diagnosed with a terminal brain tumor have chosen palliative care. Which interventions will be provided for this infant? Select all that apply.

pain management and comfort measures parental support enabling the parents to participate in the infant's care

When checking a 5-month-old infant, which symptom would alert the nurse that the infant needs further follow-up?

presence of Moro embrace reflex

Which developmental milestone would the nurse expect an 11-month-old infant to have achieved?

sitting independently

Four children, each 6 months of age, arrive at the clinic for diphtheria-pertussis-tetanus (DPT) immunization. Which child can safely be immunized at this time?

the child with a runny nose and cough

Which finding would concern the nurse who's caring for an infant after a right femoral cardiac catheterization?

weak right dorsalis pedis pulse

A 2-month-old infant arrives in the emergency department with a heart rate of 180 beats/minute and a temperature of 103.1° F (39.5° C) rectally. Which intervention is most appropriate?

Give acetaminophen.

A 4-month-old is scheduled for an upper GI series to determine whether the infant has gastroesophageal reflux. The X-ray department is busy and the test, which was scheduled for 8 a.m. (0800), becomes delayed until 2 p.m. (1400). Which pediatric patient right is being violated by the test delay?

To have procedures scheduled so that fluids and food aren't withheld for prolonged periods

A neonate is recovering from surgery to repair a cleft lip. What should the nurse do to prevent trauma to the suture line?

Use a bulb syringe with a rubber tip for feedings.

The nurse is preparing to administer pediatric eye drops to a 9 month old. Which of the following interventions would be in the nurse's plan of care? Select all that apply.

-Wash hands. -Place the drop in the conjunctival sac. -Put on gloves. -Pull the lower lid down.

A 10-month-old infant with bacterial meningitis was just started on antibiotic therapy. Which nursing action is especially important in this situation?

Wear a mask while providing care.

When presenting an informational series on infant safety, which appropriate development milestone for the 4-month-old infant would the nurse stress could jeopardize the infant's safety?

turns from abdomen to back

The nurse is gathering data on a 1-month-old infant. Which data obtained by the parents indicate the infant may have a cardiac defect?

The infant is not taking formula well.

An infant is being treated with antibiotic therapy for otitis media and develops an erythematous, fine, raised rash in the groin and suprapubic area. Which explanation would the nurse suspect?

The infant most likely has candidiasis.

Which nursing intervention provides the best support to the parents of an infant diagnosed with pyloric stenosis?

Keep the parents informed of the infant's progress.

If an infant's I.V. access site is in an extremity, the nurse should:

use a padded board to secure the extremity.

The nurse is reinforcing education with parents about therapeutic management of their neonate diagnosed with congenital hypothyroidism. Which response by a parent would indicate the need for further education?

"As my baby grows, his thyroid gland will mature and he won't need medications."

A parent is planning to enroll a 9-month-old infant in a day-care facility. The parent asks a nurse what to look for as indicators that the facility is adhering to good infection control measures. The nurse identifies which as an indication of meeting proper infection control standards? Select all that apply.

-Soiled diapers are discarded in covered receptacles. -Disposable papers are used on the diaper-changing surfaces. - Facilities for hand hygiene are located in every classroom.

The nurse is working in the emergency room and is assigned to a client with necrotizing enterocolitis. When assessing the client, the nurse should expect which finding?

Abdominal distention and gastric retention

A 10-month-old infant is found in respiratory arrest, and cardiopulmonary resuscitation is started. Which site is best to check for a pulse?

Palpation of the brachial artery is recommended. The short, chubby neck of infants makes rapid location of the carotid artery difficult. After age 1, the carotid would be used. The femoral pulse, often palpated in a hospital setting, may be difficult to assess because of the infant's position, fat folds, and clothing. The radial pulse isn't a good indicator of central artery perfusion.

The skin in the diaper area of a 6-month-old infant is excoriated and red. Which instructions would the nurse give to the parent?

Change the diaper more often.

A nurse is teaching the parents of an infant with clubfeet about cast care. Which statement by the father indicates the need for further teaching?

"Immunizations will have to be delayed until the casts come off."

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

Maintaining a consistent, structured environment

Which intervention should be included in the care plan for children with an increased risk of sudden infant death syndrome (SIDS)?

home apnea monitoring

The parents of an 11-month-old are concerned because the frequency of their infant's bowel movements has decreased from three to four each day to one to two each day. Which response by the nurse is best?

"By age 11 months, most infants have one to two bowel movements per day."

A nurse is caring for a neonate who has hypospadias. His parents are asking about having the baby circumcised before discharge. When reinforcing education with the parents about their child's condition, what should the nurse tell them?

"Circumcision is delayed as the foreskin is needed for surgical correction.

For the last 6 days, a 7-month-old infant has been receiving amoxicillin trihydrate to treat an ear infection. Now the parents report redness in the diaper area and small, red patches on the infant's inner thighs and buttocks. After diagnosing Candida albicans, the physician prescribes topical nystatin to be applied to the perineum four times daily. Medication teaching should include which instruction?

"Inspect your infant's mouth for white patches."

A mother brings her 8-month-old son to the pediatrician's office. When the nurse approaches to measure the child's vital signs, he clings to his mother tightly and starts to cry. The mother says, "He used to smile at everyone. I don't know why he's acting this way." Which response by the nurse would help the mother understand her child's behavior?

"Your baby's behavior indicates stranger anxiety, which is common at his age."

Which nursing intervention has the highest priority in the care of an infant during the first 24 hours after surgery for cleft lip?

Carefully clean the suture line after feedings using sterile technique.

A 2-month-old with a history of hydrocephalus is admitted to the pediatric unit with pneumonia. The infant's respiratory status deteriorates and the physician explains to the family that the infant requires intensive care. The grandmother convinces the parents to refuse transfer and institute comfort measures. Which action should the nurse take?

Ask to speak to the parents privately without the grandmother present.

When preparing to feed an infant with pyloric stenosis, which intervention should the nurse give highest priority?

Burp the infant frequently.

The nurse is administering medication to a 6-week-old infant. Which factor is the nurse most correct to identify as likely to decrease the infant's ability for drug metabolism?

Inefficient liver function

Which activity should be recommended for long-term support of parents who have lost an infant due to sudden infant death syndrome (SIDS)?

attending support groups

A client has been diagnosed with croup and is experiencing increased respiratory distress. What would the nurse expect to see in this client?

intercostal retractions

The parent of a neonate born with a cleft lip and palate prepares to feed the child for the first time. Which parent education should the nurse complete as a priority of care before the parent attempts the first feeding?

proper positioning of the neonate

An infant with hypothyroidism is receiving oral thyroid hormone. Which assessment finding should alert a nurse to a potential overdose?

tachycardia, irritability, and diaphoresis

Sudden infant death syndrome (SIDS) is one of the most common causes of death in infants. At what age is SIDS most likely to occur?

1 week to 1 year, peaking at 2 to 4 months

Which nursing intervention is essential in the care of an infant with cleft lip and palate?

Involve the parents in the infant's care.

The nurse is observing an infant who may have acute bacterial meningitis. Which finding should the nurse anticipate?

Irritability, fever, and vomiting

Which precaution should a nurse caring for a 2-month-old infant with respiratory syncytial virus (RSV) take to prevent the spread of infection?

wear gown, gloves, and mask

When planning to administer medication to a 3-month-old infant, the nurse should keep which consideration in mind?

An infant's kidneys excrete drugs more slowly than an adult's.