Infants
A nurse is performing a respiratory assessment of an 8-month-old child with the diagnosis of viral pneumonia. The nurse identifies bronchial breath sounds over areas of consolidation, mild substernal retractions, profuse mucus production, pallor, and a temperature of 102° F (38.9° C). What is the priority nursing action? A. Suctioning the nasopharynx so a patent airway can be maintained. B. Starting an IV infusion to provide necessary fluids and electrolytes. C. Calling the respiratory therapist to start preparations for oxygen administration. D. Notifying the practitioner of the fever so a prescription for an antipyretic can be issued.
ANS: A
A 6-month-old infant is to be on nothing-by-mouth (NPO) status for 4 hours before surgery for cleft palate repair. What is the most important concern for the infant before surgery? A. Altered fluid intake before surgery B. Difficulty of respiration caused by the cleft C. Increased tension before the hospitalization D. Regression related to the duration of hospitalization
ANS: A A 6-month-old, whose body weight is approximately 75% water, is very susceptible to fluid changes and ensuing dehydration. Although the parents may be anxious, the infant is too young to be aware of the impending hospitalization. Regressed behavior should not be a problem for a short-term hospitalization.
On a routine visit to the pediatric clinic, the mother of a 6-week-old infant tells the nurse that her baby has the "cutest little folds on her legs, two on one side, and three on the other." What might this sign indicate? A. Hip dysplasia B. Neonatal obesity C. Slipped epiphysis D. Talipes equinovarus
ANS: A Asymmetrical hips and thigh folds are indicative of developmental dysplasia of the hip; they are caused by upward and outward displacement of the femoral head on the affected side. (B) is indicated by bilateral extra folds. (C) is found in the school-aged child and is characterized by a limp and pain in the leg. (D) is clubfoot and is a deformity of the foot.
A nurse is obtaining the health history of a 7-month-old who has had repeated episodes of otitis media. What question is most important for the nurse to include in the interview with the mother? A. "Please describe your child's feeding pattern." B. "Tell me how often your child has had ear infections." C. "What medicine do you give your child for the ear infections?" D. "Do any of your children other than your baby have this problem?"
ANS: A It is important to determine the infant's feeding patterns, because drinking formula from a bottle while in a recumbent position may lead to a pooling of fluid in the pharyngeal cavity, which hinders eustachian tube drainage.
A nurse is assessing the oral cavity of a 6-month-old infant. The parent asks which teeth will erupt first. What is the nurse's response? A. Incisors B. Canines C. Upper molars D. Lower molars
ANS: A The bottom incisions are the first teeth the erupt, between 6 and 8 months of age. The canine teeth appear around 18 months. The first molars, both upper and lower, appear around 20 months.
An infant with tetralogy of Fallot begins to cry frantically and exhibits worsening cyanosis and dyspnea. In which position should the nurse place the child? A. Knee-chest B. Orthopneic C. Lateral Sims D. Semi-Fowler
ANS: A The knee-chest position decreases circulation to and from the extremities, thereby improving circulation to the heart and lungs and increasing oxygenation. The knee-chest position ash the same effect as the squatting that is seen in the older child with tetralogy of Fallot.
Which activities should the nurse expect to see exhibited by a healthy 6-month-old infant during an evaluation of the infant's growth and development? Select all that apply. A. Playing peek-a-boo B. Turning completely over C. Reaching to be picked up D. Pulling up to a standing position E. Sitting for a short time without support
ANS: A, B, C, E
While teaching a parents' group about acute otitis media, the nurse includes the fact that among infants and children acute otitis media is an infection commonly caused by what? A. A virus B. Bacteria C. A fungus D. Rickettsia
ANS: B
A dehydrated 2-month-old infant with a history of diarrhea is admitted to the pediatric unit. Oral rehydration therapy is instituted. What is the most accurate method of monitoring the infant's hydration status? A. Counting wet diapers B. Obtaining daily weights C. Measuring intake and output D. Checking tissue turgor of the abdomen
ANS: B Although a wet diaper counts as an objective measure, it is necessary to weigh the diaper before and after the infant voids to estimate the amount of fluid loss.
A newborn is admitted to the neonatal intensive care unit (NICU) with choanal atresia. Which part of the infant's body should the nurse assess? A. Rectum B. Nasopharynx C. Intestinal tract D. Laryngopharynx
ANS: B Choanal atresia is a lack of an opening between one or both of the nasal passages and the nasopharynx. In rectal atresia, the rectum ends in a pouch and the anal canal opens into the other (nonconnected) end of the rectum.
What is the priority nursing intervention for a 6-month-old infant with bronchiolitis? A. Discouraging parental visits to conserve energy B. Monitoring skin color, anterior fontanel, and vital signs C. Wearing gown, cap, mask, and gloves when rendering care D. Promoting stimulating activities to meet developmental needs
ANS: B Continuous assessment are vital in determining the infant's oxygenation and hydration status and responses to the disease process.
What toys should a nurse suggest to the parent of a 4-month-old infant to help promote the child's growth and development? A. Push-pull toys B. Soft squee toys C. Nesting blocks and cups D. Wooden hammer and pegboard
ANS: B Soft, noisy squeeze toys are appropriate for a 4-month-old; the infant enjoys squeezing and hearing the squeak. Push-pull toys are for toddlers aged 12-24 months. Nesting toys are for toddlers aged 16 months. Banging toys are appropriate for children from 12-18 months of age.
A 6-month-old infant has a congenital right-to-left shunt defect of the heart. What clinical findings are expected when the nurse completes a history and physical assessment and reviews the child's laboratory reports? Select all that apply. A. Orthopnea B. Tissue hypoxia C. Increased hematocrit D. Frequent respiratory infections E. Bounding pulses in upper extremities
ANS: B, C When right-to-left shunting of blood occurs in a congenital heart defect, nonoxygenated blood is being circulated to the extremities, resulting in tissue hypoxia. With the hypoxic conditions in the capillaries, erythropoietin is released to signal increased production of RBCs.
A 9-month-old infant who appears well-nourished, alert, and happy is brought to the well-baby clinic for a routine physical examination. Using Freud's psychosexual stages of development, the nurse determines that the infant is in which stage? A. Genital stage B. Latency stage C. Oral-sensory stage D. Anal-urethral stage
ANS: C
While a 3-month-old infant is at the well-baby clinic for a checkup, the parents express concern that their baby still has a soft spot on the top of the head. The nurse informs the parents that their infant's anterior fontanel will close around what age? A. 6 to 8 months of age B. 9 to 12 months of age C. 12 to 18 months of age D. 19 to 36 months of age
ANS: C According to the standards of growth and development, the anterior fontanel closes between 12 and 18 months of age. Early closure may impede the growth of the infant's brain, impairing mental development. Delayed closure may indicate neurological problems.
A nurse is performing a physical examination of an infant with Down syndrome. For what anomaly should the nurse assess the child? A. Bulging fontanels B. Stiff lower extremities C. Abnormal heart sounds D. Unusual pupillary reactions
ANS: C Cardiac anomalies often accompany genetic problems such as Down Syndrome; 30-40% of affected infants also have congenital heart defects.
A 14-month-old child is admitted to the pediatric hospital with a fractured right femur. The child is placed in Bryant traction. When the parents see the child for the first time in traction, they are surprised to see both legs in traction and ask why. What information should the nurse share about Bryant traction? A. Putting both legs in traction keeps on leg from becoming longer than the other. B. Putting both legs in traction keeps the baby from turning over in bed and breaking his leg again. C. As a means of ensuring countertraction, both legs are placed in traction, and the buttocks are suspended off the bed. D. When the leg was x-rayed, the HCP apparently discovered that the other leg was broken as well.
ANS: C In young infants the body weight doesn't provide adequate countertraction to overcome the spasm of the muscles. With both legs in traction and the buttocks suspended off the bed, countertraction is sufficient to realign the femur.
A cardiac catheterization is performed on an infant. After the procedure, the leg used for the catheter insertion site becomes mottled. What is the best action by the nurse? A. Elevating the led B. Covering the leg with a blanket C. Checking the pulse in the extremity D. Notifying the primary HCP
ANS: C Some mottling is expected because of circulatory disruption and arterial spasm. Further assessment is performed to rule out arterial occlusion. Elevation of the leg is contraindicated; elevation may induce bleeding from the puncture site.
The parents of a 6-month-old infant ask the nurse about the best toy to buy for their baby. What type of toy should the nurse suggest? A. Push-pull B. Wooden blocks C. Shape-matching D. Soft stuffed animals
ANS: D A stuffed animal is the most appropriate toy for a 6-month-old infant because its safe and cuddly and requires only gross motor movement. A push-pull toy is for the older infant (9-12 months) or toddler because it encourages walking.
A nurse is caring for an infant with a cleft lip and palate. What information should the nurse include when teaching the parents about this diagnosis? A. Anticipation that these children will have psychological problems. B. Emphasis that the two defects follow the laws of Mendelian genetics C. Assurance that the defect is rare and probably will not occur twice in the same family D. Expectation that these children will have no other defect and otherwise will be healthy
ANS: D Children with a cleft lip and palate are otherwise healthy, and once a successful feeding technique is established they feed, gain weight, and thrive as expected.
What physiologic alteration does the nurse expect when assessing a 6-month-old infant with bronchiolitis (respiratory syncytial virus [RSV])? A. Decreased heart rate B. Intercostal retractions C. Increased breath sounds D. Prolonged expiratory phase
ANS: D Infectious and mechanical changes narrow the bronchial passages and make it difficult for air to leave the lungs. As a result of increased respiratory effort and decreased oxygen exchange, tachycardia may develop.
The parents of an infant born with a myelomeningocele are confused about what the primary healthcare provider has told them about the condition. What should the nurse consider before answering the parents' questions in language that they will understand? A. It is a fusion failure of the vertebral arches without herniation of cord or meninges. B. There is a defect in the base of the skull through which the brain and meninges have herniated. C. A membrane-covered sac of meninges, filled with spinal fluid, is protruding through a defect in the spine. D. A saclike cyst of meninges, containing a portion of spinal cord and fluid, is protruding through a defect in the spine.
ANS: D Myelomeningocele is a neural tube defect in which the meninges and spinal nerves protrude through the opening in the spianal column. Nerve damage may occur at or below the level of the defect. (A) describes spina bifida occulta (there is no break in the skin or protrusion of any structure). (B) describes an encephalocele (the spinal cord is not involved). (D) describes a meningocele in which there is usually no nerve damage.
A nurse is preparing for a teaching session with the parents of an infant with phenylketonuria (PKU). The parents are upset and want an explanation of why the child has this disease that they have never heard of. What should the nurse consider before responding? A. It is contracted during the birth process. B. It is a lifelong disorder of unknown origin. C. This congenital disorder was caused by an intrauterine infection. D. This autosomal recessive disorder was inherited from parents who are carriers.
ANS: D PKU is an inherited metabolic disorder; the parents do not have the disorder (autosomal recessive) because two copies of the gene (one from each parent) are necessary for expression of this disorder.
A nurse is teaching parents about treating their infant's recurrent attacks of spasmodic croup at home. What is the desired effect of the actions that the nurse teaches the parents? A. Dilation of the bronchi B. Reduction of the fever C. Depression of the cough D. Interruption of the spasm
ANS: D Spasms must be interrupted, or hypoxia will occur.
A nurse is assessing the developmental level of a healthy 5-month-old infant. What behavior does the nurse expect the child to exhibit? A. Using the pincer grasp B. Sitting without support C. Crawling across the floor D. Grasping objects voluntarily
ANS: D The 5-month-old infant's neurological development has reached the stage at which objects can be grasped voluntarily; this is considered a developmental milestone. The pincer grasp appears between 9 and 12 months of age. Sitting alone without support is usually accomplished at 6 to 8 months of age. The infant begins to crawl at 8 to 10 months of age.
The parents of a 3-month old infant who is breastfed ask the nurse how to prevent nutritional anemia. What is the best response by the nurse? A. Supplemental iron will not be needed for the first year. B. Solid foods need not be introduced until 7 or 8 months of age. C. Anemia will not develop as long as the infant is gaining weight. D. Baby cereal or an iron supplement should be given around 4 months of age.
Baby cereals are fortified with iron. The breastfed infant is ready to have this food introduced by about 4 months; if solid food are not offered by this age, an iron supplement is needed. Maternally derived iron stores are adequate for the first 5-6 months in a full-term infant. After this time iron supplementation is necessary to meet the infant's growth demands.
An infant who has been found to have developmental dysplasia of the hip (DDH) is being examined in the pediatric clinic. What clinical finding does the nurse expect to identify during the physical assessment? A. Limited abduction of the affected hip B. Downward and inward rotation of the affected hip C. Inability to flex and extend the hip on the affected side D. Free abduction of the affected hip when placed in the frog position
ANS: A Abduction of the hip is limited in the infant with DDH because the head of the femur slips out of the acetabulum and is unable to rotate. The hip can be flexed on the affected side. The frog position may be used in the treatment of DDH.
An infant has developmental dysplasia of the hip. What clinical finding should the nurse expect to note during an assessment? A. Apparent shortening of the leg B. Limited ability to adduct the affected leg C. Narrowing of the perineum with an anal stricture D. Inability to palpate movement of the femoral head
ANS: A The affected leg appears shorter because the femoral head is displaced upward. The child's ability to aBDuct, not aDDuct, the affected leg is limited.
A 9-month-old infant who appears well nourished, alert, and happy is brought to the well-baby clinic for a routine physical examination. Using Erikson's theory of development, what task does the nurse determine that the infant is in the process of achieving? A. Trust B. Industry C. Initiative D. Autonomy
ANS: A Trust is developed if the infant's needs are being met by the caregivers. The task of industry is during childhood years (6-12 years). The task of initiative is during years 3-6. The stage of autonomy is during the toddler years (1-3 years).
Electrocardiography (ECG) is scheduled for an infant who has tetralogy of Fallot. The mother asks the nurse what type of test this is and why it is done. What is the best response by the nurse? A. "It's a type of x-ray that shows us the size of the baby's heart." B. "Electrical activity in the baby's heart is recorded, then printed on graph paper." C. "It's an ultrasound procedure that produces images of the structures in the baby's heart." D. "Contrast material is injected into the baby's vein to visualize the flow of blood through the heart."
ANS: B An ECG not only records electrical impulses in the heart but can also reveal atrial and ventricular hypertrophy. (A) describes a chest x-ray. (C) describes an echocardiogram. (D) describes an angiogram.
An 11-month-old is admitted with dehydration and a serum sodium level of 120 mEq/L (120 mmol/L). Reporting of which assessment finding to the healthcare provider is a priority? A. Weight loss of 1.5 kg in 3 days B. Muscle twitching in all extremities C. Temperature increase to 100 F (37.8 C) D. Heart rate increasing from 100 to 120 beats/min
ANS: B The normal sodium level is 135 to 145 mEq/L. A priority symptom of hyponatremia is a seizure activity, which may manifest early as a muscle twitching.
A nurse is conducting a physical assessment of an infant with pyloric stenosis. What clinical findings does the nurse expect? Select all that apply. A. Boardlike abdomen B. Visible peristaltic waves C. Decreased bowel sounds D. Cramping movements in the lower abdomen E. Olive-shaped mass in the RUQ
ANS: B, E Gastric peristaltic waves are visible because the stomach is attempting to propel its contents through the stenotic pyloric sphincter. The hypertrophic muscles become elongated and is palpable as an olive-shaped mass. The upper abdomen may be distended, not boardlike, because food is unable to leave the stomach and progress through. Transmission of ingested food is interrupted, but digestive processes are intact; therefore bowel sounds are heard.
After a discussion with the primary healthcare provider, the parents of an infant with patent ductus arteriosus (PDA) ask the nurse to explain once again what PDA is. How should the nurse respond? A. The diameter of the aorta is enlarged. B. The wall between the right and left ventricles is open. C. It is narrowing of the entrance to the pulmonary artery. D. It is a connection between the pulmonary artery and the aorta.
ANS: D Before birth, oxygenated fetal blood is shunted directly into the systemic circulation by way of the ductus arteriosus, a connection between the pulmonary artery and the aorta. After birth, the increased oxygen tension causes a functional closure of the ductus arteriosus. Occasionally, especially in preterm infants, the vessel remains open causing PDA.
The nurse should assess an infant with gastroesophageal reflux for what complication? A. Bowel obstruction B. Abdominal distention C. Increased hematocrit D. Respiratory problems
ANS: D Reflux of gastric contents to the pharynx predisposes the infant to aspiration and the development of respiratory problems.
A nurse is caring for a child with chordee. The parents ask why corrective surgery is necessary. Before responding, the nurse considers that if a chordee is not surgically corrected, the child will be at increased risk for what when reaching adulthood? A. Renal failure B. Testicular cancer C. Testicular torsion D. Sexual dysfunction
ANS: D The presence of uncorrected chordee can affect a child's future sexual capabilities, because this condition will make sexual penetration impossible.
A nurse is caring for a child with a cardiac malformation associated with left-to-right shunting. What does the nurse consider the major characteristic of this type of congenital disorder? A. Increased hematocrit B. Severe growth retardation C. Clubbing of the fingers and toes D. Increased blood flow to the lungs
ANS: D With a left-to-right shunt, blood flows through a defect in the ventricular wall of the heart and is shunted from the higher pressure left side to the lower pressure right side. The increased blood flow from the right ventricle results in an increased blood flow to the lungs.