Pediatric Nursing - Infant

A parent asks, "How should I bathe my baby now that he has had surgery for his inguinal hernia?" Which instruction should the nurse give the mother? "Clean only his face and diaper area for next 2 weeks." "Use sterile sponges to cleanse the inguinal incision until healed." "Give him a sponge bath daily for 1 week." "Let him take a full tub bath daily."

"Give him a sponge bath daily for 1 week."

During a well-baby visit, a 2-month-old infant receives a diphtheria, tetanus toxoids, and acellular pertussis (DTaP) vaccine, inactivated poliovirus vaccine, hepatitis B vaccine, pneumococcal vaccine, and Haemophilus influenzae b (Hib) vaccine. The parents ask why the baby must have the Hib vaccine. How does the nurse respond? "This vaccine prevents infection by the poliovirus." "This vaccine protects against serious bacterial infections, such as meningitis." "This vaccine prevents infection by the hepatitis B virus, which can cause liver damage." "This vaccine prevents susceptible children from getting chickenpox or smallpox."

"This vaccine protects against serious bacterial infections, such as meningitis."

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

brachial artery

Which action should the nurse take next after noting that an 8-month-old child's posterior fontanel is slightly open? Check the child's head circumference. Document this as a normal finding. Question the mother about the child's labor and birth. Schedule an X-ray of the child's head.

Check the child's head circumference.

A nurse is assessing the chest of a 4-month-old infant. The nurse identifies the ratio of the anteroposterior-to-lateral diameter as 1:2. Which actions should the nurse take next? Document the findings in the client's medical record. Obtain an order for a chest X-ray. Observe for substernal retractions. Auscultate for adventitious lung sounds.

Document the findings in the client's medical record.

The nurse is teaching the parents of an 8-month-old about what the child should eat. The nurse should include which information points in the teaching plan? Vegetables should be introduced before fruits when the infant is 6 months old. Solid foods should not be introduced until the infant is 10 months old. Iron-fortified cereals should not be introduced until the infant is 8 months old. Formula can be changed to whole milk when the infant is 12 months old.

Formula can be changed to whole milk when the infant is 12 months old.

Three weeks after an infant receives a spica cast, the mother calls the nurse because the infant's toes are swollen and cool to the touch. What should the nurse instruct the mother to do? Place the child's legs in a lowered position. Have the child fitted for a larger cast. Put more cotton wadding to line the casting. Inspect the area for an infection.

Have the child fitted for a larger cast.

A nurse is caring for an infant who is in critical condition. The nurse notes that the child weighs 11 lb (5 kg) and has had a blood loss of 100 mL. Assessment reveals a decreased urine output, mild tachycardia, and restlessness. Which of the following should be the priority action for the nurse to take? neurologic assessment with the Glasgow Coma Scale application of telemetry monitoring IV administration of lactated Ringer's insertion of a Foley indwelling catheter

IV administration of lactated Ringer's

When teaching the family of an older infant who has had a spica cast applied for developmental dysplasia of the hip, which information should the nurse include when describing the abduction stabilizer bar? It can be adjusted to a position of comfort. It is used to lift the child. It adds strength to the cast. It is necessary to turn the child.

It adds strength to the cast.

The nurse is caring for an alert 2-month-old child and assesses a sunken fontanelle. Which action would be most appropriate for the nurse to take based on the assessment? Obtain the child's weight. Administer vitamin supplements. Assess for neurologic deficits. Monitor fluid intake and output.

Monitor fluid intake and output.

When assessing the chest of a 4-month-old infant, the nurse identifies the ratio of the anteroposterior-to-lateral diameter as 1:1. What action should the nurse take next? Inform the physician of the finding and obtain an order for a chest X-ray. No action is needed; this is a normal finding. Instruct the parents to bring the infant back in 1 month for reevaluation. Check the infant for signs of respiratory distress.

No action is needed; this is a normal finding.

A nurse is performing a neurologic assessment on an infant. When assessing for function of cranial nerve X (vagus), which technique is most appropriate to use? Press a tongue blade on the posterior surface of the tongue. Observe for spontaneous eye movement. Lightly brush a cotton swab across the child's cheek. Assess for smiling or forceful eye closing with crying.

Press a tongue blade on the posterior surface of the tongue.

After gathering all necessary equipment and setting up the supplies, what should be the first step in performing endotracheal (ET) or tracheal suctioning in an infant? Provide extra oxygen by using a ventilator or through manual bagging. Insert a suction catheter to the appropriate measured length. Insert a few drops of sterile saline solution. Put on clean gloves.

Provide extra oxygen by using a ventilator or through manual bagging.

An infant weighing 9 kg is in the pediatric intensive care unit (PICU) following arterial switch surgery. In the past hour, the infant has had 16 mL of urine output. Which action should the nurse take? Notify the health care provider (HCP) immediately. Record the urine output in the medical record. Administer a fluid bolus immediately. Assess for other signs of hypervolemia.

Record the urine output in the medical record.

Two parents who are arguing in their infant's room, with voices raised and getting louder, start to hit each other. The infant is crying. Which action should the staff nurse take next? Try to reason with both of the parents. Ask one of the parents to leave the room. Call security to come and break up the fight. Remove the infant from the room.

Remove the infant from the room.

Eight hours ago, an infant with Hirschsprung's disease had surgery to create a colostomy. Which finding should alert the nurse to notify the health care provider (HCP) immediately? a 3-cm increase in abdominal circumference periods of occasional fussiness absence of bowel sounds since surgery bright red stoma

a 3-cm increase in abdominal circumference

The nurse teaches the parents of an infant who has had surgery to correct imperforate anus how to position the infant to prevent tension on the perineum. The nurse determines more teaching is need when the parents put the infant in which position? back, with legs suspended at a 90-degree angle left side, with hips elevated abdomen, with legs pulled up under the body right side, with hips elevated

abdomen, with legs pulled up under the body

The nurse is providing postoperative care for an infant who had a ventriculoperitoneal shunt placed to correct hydrocephalus. Which clinical finding warrants immediate intervention? abdominal distension lethargy facial edema headache

abdominal distension

A 9-month-old, well-nourished boy who lives with his extensive extended family tests positive for tuberculosis. What is a risk factor for tuberculosis in this child? being male being in the 95th percentile for height and weight having a mother who did not receive prenatal care until the second trimester of her pregnancy being an infant

being an infant

The nurse is assessing children at risk for phenylketonuria (PKU). Which child is at greatest risk? blond, blue-eyed, fair-skinned child with eczema African descent, dark-eyed child with asthma child with dark complexion who is overweight and has labile personalities a red-headed child who experiences frequent contact dermatitis

blond, blue-eyed, fair-skinned child with eczema

An infant diagnosed with Hirschsprung's disease is scheduled to receive a temporary colostomy. When the nurse is initially discussing the diagnosis and treatment with the parents, which action by the nurse would be most appropriate? assessing the adequacy of their coping skills reassuring them that their child will be fine encouraging them to ask questions giving them printed material on the procedure

encouraging them to ask questions

The nurse is assessing a 10-month-old infant during a checkup. Which developmental milestones would the nurse expect the infant to display? Select all that apply. holding head erect self-feeding with a spoon demonstrating good bowel and bladder control sitting on a firm surface without support bearing majority of weight on legs walking alone

holding head erect sitting on a firm surface without support bearing majority of weight on legs

The mother of an infant with hemophilia tells the nurse that she is planning to do home teaching when the child reaches school age. She does not want her child in school because the teacher will not watch the child as well as she would. The mother's comments represent what common parental reaction to a child's chronic illness? devotion overprotection mistrust insecurity

overprotection

A nurse is obtaining the history of an infant with suspected acute otitis media. What should the nurse ask the parent about? covering of the infant's ears when out in the cold thorough drying of the infant's ears after a bath immunization status of the infant' position of the infant when taking a bottle

position of the infant when taking a bottle

The nurse works with the health care team to establish a policy regarding sleep positions for infants with gastroesophageal reflux. What information should the nurse search for first? policies from other hospitals data from retrospective studies published national standards expert opinions

published national standards

The nurse is caring for a 12-month-old infant with dehydration and metabolic acidosis. What assessment finding does the nurse document as congruent with dehydration and metabolic acidosis? bradycardia cyanosis shallow respirations tachypnea

tachypnea

A 10-month-old child with phenylketonuria (PKU) is being weaned from breast-feeding. When teaching the parents about the proper diet for their child, the nurse should stress the importance of restricting meats and dairy products because: they are difficult for clients with PKU to digest. they contain high levels of phenylalanine. they are not well tolerated in children with PKU until after age 2. they contain high levels of phenylketones, which inhibit muscle growth.

they contain high levels of phenylalanine.