Bronchopulmonary Dysplasia, OBE1

A nurse is caring for a hospitalized infant with bronchiolitis. Diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which of the following would be the appropriate nursing action?

1. Initiate strict enteric precautions. 2. Wear a mask when caring for the child. 3. Plan to move the infant to a room with another child with RSV. 4. Leave the infant in the present room, because RSV is not contagious. Rationale: RSV is a highly communicable disorder, but it is not transmitted via the airborne route. It is usually transferred by the hands, and meticulous handwashing is necessary to decrease the spread of organisms. The infant with RSV is isolated in a single room or placed in a room with another child with RSV. Enteric precautions are not necessary; however, the nurse should wear a gown when the soiling of clothing may occur.

A nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by the respiratory syncytial virus (RSV). Choose the interventions that would be included in the plan of care. Select all that apply.

1. Place the infant in a private room. 2. Place the infant in a room near the nurses' station. 3. Ensure that the infant's head is in a flexed position. 4. Wear a mask at all times when in contact with the infant. 5. Place the child in a tent that delivers warm, humidified air. 6. Position the infant side-lying, with the head lower than the chest. Rationale: The infant with RSV should be isolated in a private room or in a room with another child with RSV. The infant should be placed in a room near the nurses' station for close observation. The infant should be positioned with the head and chest at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and to decrease pressure on the diaphragm. Cool, humidified oxygen is delivered to relieve dyspnea, hypoxemia, and insensible water loss from tachypnea. Contact precautions (wearing gloves and a gown) reduce the nosocomial transmission of RSV.

Which finding would the nurse consider abnormal when performing a physical assessment on a 6-month-old? 1. Posterior fontanel is open. 2. Anterior fontanel is open. 3. Beginning signs of tooth eruption. 4. Able to track and follow objects.

1. The posterior fontanel should close between 6 and 8 weeks of age.

Which toy is the best choice for a 12-month-old? 1. Baby doll. 2. Musical rattle. 3. Board book. 4. Colorful beads.

2. A musical rattle is the perfect toy for this child. Infants have short attention spans and enjoy auditory and visual stimulation.

The nurse is going to give a 6-month-old a dose of Rocephin IM. What must the nurse do when the 1.5-mL dose arrives from the pharmacy? 1. Administer the injection into the deltoid muscle. 2. Divide the dose into two injections. 3. Administer the injection into the dorsogluteal muscle. 4. Give dose as a single injection into the vastus lateralis muscle.

2. A nurse should not deliver more than 1 mL per IM injection to a 6-month-old.

Which statement by an infant's mother leads the nurse to believe that she needs further education about the nutritional needs of a 6-month-old? 1. "I will continue to breastfeed my son and will give him rice cereal three times a day." 2. "I will start my son on fruits and gradually introduce vegetables." 3. "I will start my son on carrots and will introduce one new vegetable every few days." 4. "I will not give my son any more than 8 ounces of baby juice per day."

2. Infants should be started on vegetables prior to fruits. The sweetness of fruits may inhibit infants from taking vegetables.

A first-time mother brings in her 5-day-old baby for a well-child visit. The nurse weighs the infant and reports a weight of 7 lb 5 oz to the mother. The mother looks concerned and tells the nurse that her baby weighed 7 lb 10 oz when she was discharged 4 days ago. The nurse's best response to the mother is: 1. "I will let the doctor know, and he will talk with you about possible causes of your infant's weight loss." 2. "Al weight loss of a few ounces is common among newborns, especially for bre

2. Newborns can lose up to 10% of their birth weight without concern but should regain their birth weight by 2 weeks of age.

The mother of a newborn asks the nurse when the infant will receive the first hepatitis B immunization. Which is the nurse's best response? 1. "Babies receive the hepatitis B vaccine only if their mother is hepatitis B-positive." 2. "The first dose of the hepatitis B vaccine will be given prior to discharge today." 3. "The first dose of hepatitis B vaccine is given at 1 year of age." 4. "Babies receive their first hepatitis B vaccine at 6 months of age."

2. The first dose of hepatitis B vaccine is recommended between birth and 2 months. In most hospitals, newborns are given the vaccine prior to discharge.

A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory distress syndrome. Which assessment signs if noted in the newborn infant would alert the nurse to the possibility of this syndrome? 1. Hypotension and Bradycardia 2. Tachypnea and retractions 3. Acrocyanosis and grunting 4. The presence of a barrel chest with grunting

2. The infant with respiratory distress syndrome may present with signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts.

A mother requests that her child receive the varicella vaccine at the 9-month well-child checkup. The nurse tells the mother that: 1. Children who are vaccinated will likely develop a mild case of the disease. 2. The vaccine cannot be given at that visit. 3. The vaccine will be administered after the physician examines the child. 4. A booster vaccination will be needed at 18 months of age.

2. The nurse should not give the vaccine. The varicella vaccine is not usually administered prior to 1 year of age.

2. The nurse at a pediatric clinic is assessing a 11-year-old male. The patient expresses concern about physical changes he is experiencing and indicates his development is ahead of his friends' development. He asks why the changes are occurring. Which response by the nurse is most appropriate? 1. "Everyone has sex glands. In boys, those are the testes. In girls, ovaries." 2. "These changes are normal and expected at your age. Don't worry." 3. "Your body is releasing more hormon

3. "Your body is releasing more hormones that cause growth, increases in facial and body hair, and muscle development."

How can the nurse best facilitate the trust relationship between infant and parents while the infant is hospitalized? The nurse should: 1. Encourage the parents to remain at their child's bedside as much as possible. 2. Keep parents informed about all aspects of their child's condition. 3. Encourage the parents to hold their child as much as possible. 4. Advise the parents to participate actively in their child's care.

3. Having parents hold their child while in the hospital is an excellent means of building the trust relationship. Infants are most secure when they are being held, patted, and spoken to.

A 6-month-old male is at his well-child checkup. The nurse weighs him, and his mother asks if his weight is normal for his age. The nurse's best response is: 1. "At 6 months his weight should be approximately three times his birth weight." 2. "Each child gains weight at his or her own pace." 3. "At 6 months his weight should be approximately twice his birth weight." 4. "At 6 months a child should weigh about 10 lb more than his or her birth weight."

3. Infants should double their birth weight by 4 to 6 months of age.

The nurse is instructing a new breastfeeding mother in the need to provide her premature infant with an adequate source of iron in her diet. Which statement reflects a need for further education of the new mother? 1. "I will use only breast milk or an iron-fortified formula as a source of milk for my baby until she is at least 12 months old." 2. "My baby will need to have iron supplements introduced when she is 4 months old." 3. "I will need to add iron supplements to my baby's diet when she is

3. Premature infants have iron stores from the mother that last approximately 2 months, so it is important to introduce an iron supplement by 2 months of age. Full-term infants have iron stores that last approximately 4 to 6 months

A nurse on the newborn nursery floor is caring for a neonate. On assessment the infant is exhibiting signs of cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress syndrome is diagnosed, and the physician prescribes surfactant replacement therapy. The nurse would prepare to administer this therapy by: 1. Subcutaneous injection 2. Intravenous injection 3. Instillation of the preparation into the lungs through an endotracheal tube 4. Intramuscular injection

3. The aim of therapy in RDS is to support the disease until the disease runs its course with the subsequent development of surfactant. The infant may benefit from surfactant replacement therapy. In surfactant replacement, an exogenous surfactant preparation is instilled into the lungs through an endotracheal tube.

The parents of a newborn are asking the nurse how to use the infant car seat and where it should be placed in their vehicle. Which is the next most appropriate action by the nurse? 1. Give the parents a pamphlet explaining how to install the car seat. 2. Accompany the parents to the car, and show them how to install the car seat. 3. Contact the hospital's car-seat safety officer, and ask the officer to accompany the parents to the car for car-seat installation. 4. Show the parents a video on c

3. The car-seat safety officer is the best choice, as that individual would have the needed information and certification to help the family.

Which statement accurately describes the best method for assessing a 12-month-old? 1. The nurse should assess the child on the examining table. 2. The nurse should assess the child in a head-to-toe sequence. 3. The nurse should have the child's mother assist in holding her down. 4. The nurse should assess the child while she is in her mother's lap.

4. Infants are most secure when in proximity to the parent. The parent's lap is an excellent place to assess the child.

which nursing action would be most appropriate to facilitate gas exchange for an infant with bronchopulmonary dysplasia a. provide or arrange for chest physiotherapy b. provide adequate rest periods c. monitor oxygen saturation d. promote bonding between parent and child

A (actively facilitates gas exchange by mobilizing secretions)

The maternity nurse is providing instructions to a new mother regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial development theory, the nurse instructs the mother to take which measure? A - allow the newborn infant to signal a need B - anticipate all needs of the newborn infant C - attend to the newborn infant immediately when crying D - avoid the newborn infant during the first 10 minutes of crying

A - allow the newborn infant to signal a need

A parent of a 3yr old tells a clinic nurse that the child is rebelling constantly and having temper tantrums. Using Erikson's psychosocial development theory, which instructions should the nurse provide to the parent? SELEC ALL THAT APPLY A - set limits on the child's behavior B - ignore the child when this behavior occurs C - allow the behavior, because this is normal at this age period D - provide a simple explanation of why the behavior is unacceptable E - punish the child every time the chi

A - set limits on the child's behavior D - provide a simple explanation of why the behavior is unacceptable

The nurse is describing Piaget's cognitive developmental theory to pediatric nursing staff. The nurse should tell that staff that which child behavior is characteristic of the formal operations stage? A - the child has the ability to think abstractly B - the child begins to understand the environment C - the child is able to classify, order, and sort facts D - the child learns to think in terms of past, present, and future

A - the child has the ability to think abstractly

5. An infant with a congenital heart defect is receiving palivizumab (Synagis). The purpose of this is to: A. prevent RSV infection. B. prevent secondary bacterial infection. C. decrease toxicity of antiviral agents. D. make isolation of infant with RSV unnecessary.

A. prevent RSV infection. Synagis is a monoclonal antibody specific for RSV. Monthly administration is initiated to prevent infection with RSV. Given monthly (28-31 days apart)

The pediatric home-care nurse is visiting a toddler born with a genetically related illness. Which comment by the parent is the greatest cause for the nurse to assess for additional information? 1. "I am having more difficulty keeping her confined." 2. "A chronically ill child affects the entire family." 3. "The other children seem so accepting of the illness." 4. "Hospitalization would cause some severe stress."

ANS 1 1 This is correct. When the parent states increasing difficulty keeping this toddler confined, the nurse needs to assess for additional information. The nurse needs to reinforce that play is what children do, and playing is important to learn the developmental skills needed to reach the most optimal functioning. Confinement may not be appropriate. 2 This is incorrect. The parent is expressing a truth; chronically ill children do affect the entire family. However, this is not the comment that gives the nurse the greatest cause for seeking additional information. 3 This is incorrect. Other children, especially siblings, often accept the chronically ill child without difficulty. This is not the comment that gives the nurse cause to seek additional information. 4 This is incorrect. It is true that hospitalization of a child does cause severe stress on the child and family members. However, the comment that causes the nurse to seek additional information is related to promoting beh

The nurse in a pediatric clinic is performing well-baby checks. The nurse is checking an infant who is 7 months old for developmental milestones. Which finding is of greatest concern to the nurse? 1. The infant remains flat when in a prone position. 2. The infant exhibits a Babinski reflex. 3. The infant opens and closes her hands to grasp objects. 4. The infant exhibits a lack of startle reflex to sound.

ANS: 1 An infant should be able at the age of 2 to 3 months to raise the head and chest and support the upper body with arms while in a prone position. The finding that the infant at 7 months lies flat when placed prone is a matter of concern to the nurse. It is not a matter of concern to the nurse if the 7-month-old infant still exhibits a Babinski sign. The Babinski reflex disappears by the age of 1 year. The ability to grasp objects by opening and closing the hands is normally present at the age of 2 to 3 months. The presence of this skill is expected to continue. This ability alone is not a reason for concern; however, assessment for progression is important. The startle reflex disappears around 4 to 6 months; the absence of this reflex in a 7-month-old infant is not cause for concern.

During a well-baby checkup, the mother of an infant states, "Even if he is occupied with a toy, he cries as soon as he notices I have left the room." Which explanation by the nurse is best? 1. "Your baby does not know you exist if he cannot see you." 2. "Babies learn very quickly how to get an adult's attention." 3. "You should move the baby with you if you leave the room." 4. "Just ignore him; he will soon learn that you are still present."

ANS: 1 Object permanence is one of the most important developments in the sensorimotor stage. The child will learn that an object exists even when it cannot be seen or heard. Prior to this, the child does not understand that someone or something did not disappear. Playing peek-a-boo is a good way to help the development of object permanence. The nurse's comment is not the best answer; the baby is most likely to cry because of a lack of object permanence. Instructing the mother to move the baby when she leaves the room is not the best answer. The nurse needs to explain the development of object permanence and share ideas of how to assist the development. Ignoring the baby is not the best suggestion. The mother needs to understand what development is taking place and how to assist in the process

The nurse is counseling parents about management of their children who are 2, 4, and 6 years of age. One of the parents states, "We believe in Kohlberg's theory of social-moral development." The nurse is aware that the preconventional stage of this theory involves which characteristic? 1. Behavior is adjusted according to good/bad and right/wrong thinking. 2. A personal and functional value system is constructed by the child. 3. The focus of the child is on following rules and maintaining social

ANS: 1 The children in the family are all in the preconventional level of Kohlberg's theory. Stages include obedience and punishment orientation, and individualism and exchange. Characteristics include following rules set by those in authority and behavior adjusted according to good/bad and right/wrong thinking. A personal and functional value system is constructed by the child and is a characteristic of the postconventional autonomous level of Kohlberg's theory. When the focus of the child is on following rules and maintaining social order, the nurse recognizes the conventional level of Kohlberg's theory. When a child's value systems are independent of authority figures and peers, the child is exhibiting the characteristics of the postconventional autonomous level of Kohlberg's theory

The nurse in a pediatric clinic is counseling a parent who expresses concern about a toddler who plays alone at daycare and does not interact with the other children who are present. Which information does the nurse provide to alleviate the parent's concern? 1. Parallel play is being exhibited and is normal at this age. 2. The toddler is likely to grow into a shy, introverted adult. 3. It is important for the child to learn to be alone at this age. 4. The toddler is exhibiting the normal behavio

ANS: 1 Using knowledge about Erikson's theory of psychosocial growth and development, the nurse needs to reassure the parent that the toddler is expected to exhibit parallel play. Parallel play is part of the autonomy versus shame and doubt stage of Erikson's theory; autonomy and independence is being developed. The toddler's play behavior is normal and is not an indication of becoming a shy, introverted adult. The manner of play being exhibited by the toddler is more closely related to the development of autonomy and independence and not part of learning to be alone. Solitary play is expected during Erikson's stage of trust versus mistrust (birth to 1 year) and is not what the toddler is exhibiting.

A widowed parent of two children informs the nurse of an upcoming marriage to a woman who has three children. The expressed intention is to adopt the three stepchildren. Which definition of family will the nurse apply? Select all that apply. 1. A nuclear family after the adoption of the stepchildren. 2. A nonnuclear family after the marriage has taken place. 3. A blended family after the marriage of the adults occurs. 4. A nuclear family before adoption if all children live in the home. 5. A ble

ANS: 1, 2, 3 1. This is correct. The nuclear family is composed of a mother, a father, and a biological or adopted child or children. 2. This is correct. The term nonnuclear family describes family forms other than traditional, such as single-parent homes, grandparents functioning in the role of parents, same-sex parents with a child or children, and blended families. 3. This is correct. Blended families are those in which families from divorce are joined together by remarriage. This can also occur when a spouse has died and the remaining spouse remarries. 4. This is incorrect. The blended family does not become a nuclear family just because all the children live in the same home. 5. This is incorrect. The term blended family is not applied until after marriage occurs between two persons, each having biological children.

The nurses at a community pediatric clinic are preparing a presentation about nutrition for the school-age child. Which information is important for the nurses to include? Select all that apply. 1. Over 35% of school-age children are considered to be obese or overweight. 2. Overweight children have an increased likelihood of being overweight adults. 3. Children with a high body mass index (BMI) have increased levels of lipids, insulin, and blood pressure. 4. Notably higher health risks exist fo

ANS: 1, 2, 3, 4

The school nurse is asked to assess a student in the third grade who is failing to demonstrate academic success. Using Maslow's hierarchy of needs, the nurse can create a needs list based on which comments by the student? Select all that apply. 1. "I have to go to bed at 10:00 every night." 2. "I worry because my mom and dad fight all the time." 3. "Game and movie nights are always fun at my house." 4. "My grandma says I'm stupid just like my mother." 5. "I taught my little brother to ride a bik

ANS: 1, 2, 4 1. This is correct. If the student in question goes to bed every night at 10:00 the nurse recognizes a physiological need that is not being met. Children need more sleep than adults. Sleep deprivation can impact the growth and development of a child and cause delays. 2. This is correct. If the student in question expresses worry about fighting between parents, the nurse recognizes the child has the need to be protected from harm and may not feel safe. Fear and worry can interfere with developmental achievements. 4. This is correct. Negative feedback interferes with the development of esteem, which is related to the need to respect one's self and be respected by others. 3. This is incorrect. When the student in question expresses pleasure during family game and movie nights, the student feels loved and has a sense of belonging. 5. This incorrect. The student is expressing the feeling of self-esteem related to successfully teaching a sibling a physical skill.

The nurse is gathering information during a routine checkup for a preschool-age child who lives with grandparents. The grandmother expresses distress about "how loud and busy" the child is, and "how expensive it is to feed and clothe" the child. Which referrals does the nurse make to the grandmother? Select all that apply. 1. Community programs for the child aimed at playing and learning 2. Social service for determination of benefits available for the care of the child 3. Legal services to assi

ANS: 1, 2, 5 1. This is correct. The grandmother's statement indicates stress related to the expected behavior of a preschool child. A referral for community programs for the child aimed at playing and learning is appropriate and beneficial. 2. This is correct. The nurse needs to make a referral to social services who can determine if the household is entitled to assistance for raising a grandchild. Services can include food, clothing, childcare, and medical services, to name a few. 5. This is correct. The nurse needs to be sensitive that the grandmother may be expressing caregiver stress. The nurse needs to make referrals to programs that can benefit the grandparents physically, psychosocially, and spiritually. 3. This is incorrect. The nurse does not have enough information to make a referral to legal services. The scenario does not clarify the reasons why the child is being raised by grandparents. 4. This is incorrect. The scenario does not provide any information indicating the chi

The nurses on a pediatric unit are concerned about developmental delays in patients who are hospitalized frequently and for extended periods of time. Which interventions do the nurses initiate to alleviate the concerns? Select all that apply. 1. Design a play/recreational area with age-appropriate sections. 2. Provide nurses with allotted time to play with confined children. 3. Extend the services of the child-life specialists to all patients. 4. Encourage family to bring favorite toys and books

ANS: 1, 3, 5 1. This is correct. Play is what children do and should not be overlooked when a child is in the hospital. Play is important for younger children to build the skills needed for development. All ages of pediatric patients can use play as a stress reducer. 3. This is correct. Many pediatric facilities have a child-life specialist on staff who can assist the child in fostering growth and developmental needs through play. An extension of services to meet the needs of all hospitalized children is appropriate. 5. This is correct. When hospitalized, patients will view TV as a distraction to the manifestations of illness and effects of treatment. However, with pediatric patients, TV provides an opportunity for skills development as well as entertainment. 2. This is incorrect. Confined children will benefit from designated play time. However, the pediatric nurse is focused on nursing care. A better plan is to have a program where volunteers will come and play with patients who are

The pediatric nurse is providing care for a 14-year-old female patient. After the patient's parents leave the hospital, the patient begins to cry. The nurse explores the patient's feelings using therapeutic communication. Which information causes the nurse to report suspected sexual abuse? 1. The patient is frequently denied access to needed health care. 2. The patient reports frequent episodes of genital irritation. 3. The patient admits to multiple incidences of skipping school. 4. The patient

ANS: 2 2 This is correct. Frequent episodes of genital irritation is indicative of possible sexual abuse and should be reported as such 1 This is incorrect. Being denied needed medical attention is an indication of medical neglect and should be reported as such.. 3 This is incorrect. The patient's admission of multiple incidences of skipping school may or may not indicate educational neglect; additional information is needed. 4 This is incorrect. When the patient reports that an older brother "hurts" her, the nurse recognizes possible physical abuse; however, sexual abuse may or may not be present. Additional information is needed before reporting sexual abuse, but physical abuse is reported.

The nurse in a pediatric clinic is checking the developmental milestones for a 3-year-old patient. Which finding causes the nurse to perform additional assessments? 1. The patient's tee-shirt is on backward. 2. The patient loses balance when kicking a ball. 3. The patient draws a circle that is closed but oblong. 4. The patient jumps with both feet about 2 inches high.

ANS: 2 Between the ages of 2 to 3 years, a toddler should be able to kick a ball. The fact that the patient loses balance when attempting this skill may require additional assessment. At the age of 3 years, the patient is beginning to self-dress; the backward shirt indicates the skill is developing but not refined. The backward shirt may also be indicative of toddler independence. Toddlers correctly draw a circle when the curved line is closed; the shape is not the most important factor. No matter how high, jumping with both feet off the floor is an expected developmental skill for a toddler.

The nurse works in an elementary school with students ranging from 6 to 11 years of age. The nurse uses knowledge related to Freud's psychosocial theory to identify which behavior in this pediatric population? 1. Oedipal or Electra conflicts 2. Energy focused on socialization 3. Curiosity about anatomical differences 4. Mild struggles with sexuality

ANS: 2 The energy focus is on socialization and increasing problem-solving abilities. Oedipal or Electra conflicts, which existed during the phallic stage, are resolved during the latency stage (6 to 11 years of age). Curiosity about anatomical differences occurs in the phallic stage. The school-aged child's sexual drives are submerged

The nurse in a pediatric clinic is performing an assessment on an infant in the presence of both parents. The parents are short and moderately overweight. The father states, "We are going to do everything we can to raise a strong, tall, athletic child." How does the nurse respond? 1. Provides materials about healthy diets and lifestyles for families 2. Shares the impact of genetics and environmental conditions on growth 3. Suggests to the parents how to alter their lifestyles 4. Recognizes the p

ANS: 2 The nurse is aware that nature involves the traits, capacities, and limitations that a person inherits from parents at conception. Genetically, the infant may not become tall due to any nurturing behaviors; however, the infant can be strong and athletic because of nurturing. Materials for healthy diets and lifestyles may be helpful for the parents to alter their behaviors and implement good nurturing skills into their parenting; however, the topic of nature also needs to be addressed. At some point, the nurse can introduce information about how the parents can alter their lifestyles and positively impact the nurturing of their infant. At this time there is a more immediate need. The nurse needs to clarify the impact of both nature and nurturing during the infant's lifetime.

Erickson's psychosocial development theory proposes that the school-aged child between ages 6 and 12 years is in the stage of industry vs. inferiority. Based on this theory, how will the pediatric nurse design activities as part of a diversional program for children who are in a long-term medical facility? Select all that apply. 1. Identify adequate activities suited for solitary play. 2. Provide activities that involve more than one person. 3. Allow participation in simple tasks on the unit of

ANS: 2, 3, 4, 5 2. This is correct. The school-aged child enjoys working in groups and forming social relationships. 3. This is correct. Developing a sense of industry provides the child with purpose and confidence in being successful; participation in small tasks will fulfill this need. 4. This is correct. If a child is unable to be successful, this can result in a sense of inferiority. Success needs to be recognized and rewarded. 5. This is correct. The school-aged child in this stage follows the rules and likes order. 1. This is incorrect. Play during this stage is known as cooperative play and involves more than one person

The nurse is performing a clinic assessment on a 1-month-old new patient. During the interview, the mother shares personal information. Which comments will cause the nurse concern about growth and development? Select all that apply. 1. "I was anemic during pregnancy and still take iron pills." 2. "Fat people are gross; I only gained 16 pounds during pregnancy." 3. "I don't think I even had a single cold during my pregnancy." 4. "During my pregnancy I never even took care of the cat." 5. "I reall

ANS: 2, 5 2 This is correct. The nurse is concerned by this comment on two levels. Poor nutrition in the mother can lead to low-birth-weight babies, as well as slow development, compromised neurological performance, and impaired immune status. The mother's attitude about "fat people" may carry over through the lifetime of the infant and cause insufficient nutrition for growth and development and/or psychosocial issues. 5. This is correct. Maternal smoking can result in infants with low birth weight and/or congenital anomalies such as cleft lip and cleft palate. The nurse needs to provide teaching about the effects of smoking during pregnancy, especially if another pregnancy is planned. 3. This is incorrect. The comment by the mother that she was healthy during pregnancy does not cause the nurse concern. Certain maternal illnesses can harm the fetus, such as rubella. 4. This is incorrect. The avoidance of cat feces during pregnancy does not cause the nurse concern. 1. This is incorrec

The nurse is performing a development assessment on a 3-month-old infant who was 6 weeks premature. The nurse states the infant's development is normal. The parent expresses that the baby seems behind what other babies the same age are doing. Which information does the nurse share to provide reassurance to the parent? 1. The infant will catch up developmentally by age 1 year. 2. Developmental milestones vary from infant to infant. 3. The infant's age is adjusted because of prematurity. 4. Each i

ANS: 3 3 This is correct. Premature infants can experience delayed growth and development and are thus expected to reach developmental milestones at the same age they would have reached them if born at normal gestational age. Age is adjusted for assessments: subtract the weeks/months that the infant was born prematurely from the current chronological age 1 This is incorrect. The premature infant is expected to catch up developmentally by 2 years of age. 2 This is incorrect. Developmental milestone have a narrow range for normal; variation is not extensive.. 4 This is correct. Infants are unique; however, the ranges set for developmental milestones are accurate enough for early detection of delays and other issues.

The nurse is visiting the home of a new mother and a 2-month-old infant. The nurse notices the infant vigorously sucking on the fist and whining but not crying. The mother validates that the behavior is common. Which information does the nurse need to obtain from the mother? 1. If the mother is breast or bottle feeding 2. How long the infant sleeps at night 3. What type of feeding schedule is followed 4. If the infant draws up the legs when crying

ANS: 3 Normal development requires not depriving oral gratification, such as weaning too soon or a rigid feeding schedule. Because of the infant's vigorous fist sucking, the nurse needs to ascertain what type of feeding schedule is being followed. Freud's psychosexual theory states that from birth to 1 year, sexual gratification is achieved orally. However, it is not important if the mother breast or bottle feeds her infant. The infant may be attempting to gratify sexual urges with oral behaviors such as sucking, biting, chewing, and eating. It is not important to the nurse how long the infant sleeps at night. Asking if the infant draws up the legs when crying may be assessing for the presence of colic; the information is not related to the infant's

The school nurse in a high school setting expresses concern to school administration regarding the increase in student complaints about bullying, physical violence, and rejection. Which concern related to psychosocial development does the nurse share as being most important? 1. Students are preoccupied with how they are seen in the eyes of others. 2. Students who are bullied will develop issues related to sexual orientation. 3. Students may be unable to provide a meaningful definition of self. 4

ANS: 3 The nurse's concern is focused on the possibility the students involved in any aspect of bullying, physical violence, and rejection will be unable to provide a meaningful definition of self, which places them at risk for role confusion in one or more roles throughout life. During the identity versus role confusion stage of Erikson's theory, 12- to 18-year-olds are preoccupied with how they are seen in the eyes of others. However, this manifestation exists even in the absence of peer violence. Sexual orientation issues are not manifestations of bullying; however, sexual orientation can cause a person to be a target for bullying and other violence. Students who are aggressive may develop a strong sense of guilt as adults, but this is just one aspect of the impact of bullying, physical violence, and rejection—not the most important one

A mother of a 9-month-old infant asks the nurse about what toys are age appropriate. Using Piaget's theory of development, which toy does the nurse recommend? 1. Building blocks 2. Colorful mobiles 3. Picture books 4. Musical rattles

ANS: 4 At 8 months, the infant should be in Piaget's stage 4: coordination of secondary schemata. To achieve a desired effect, the infant will repeat an action, such as repeatedly shaking a rattle to make sounds. The nurse will recommend a variety of rattles as appropriate toys for this patient. The nurse would not expect an infant of 8 months of age to play with building blocks. An 8-month-old infant may or may not be interested in a colorful mobile. Tactile stimulation from this would be limited for safety reasons. An infant's interest in picture books is more likely to occur in Piaget's stage 6: inventions of new means/mental combinations, which occurs between 18 and 24 months.

The nurse is teaching a parenting class being held in a community clinic. The nurse is focusing on behaviors that will assist in increasing the number of children who score well in kindergarten readiness screening. Which comment by a parent indicates the need for additional information? 1. "I am not athletic, but the kids would love an outdoor play area." 2. "Practicing counting with the kids while traveling is a good idea." 3. "I like the suggestion to label basic items for word recognition." 4

ANS: 4 The nurse needs to provide additional information to the parent who thinks books are a waste of money. The parent needs to be aware of community agencies that will supply books to children and of programs that provide reading/story times. The nurse's information is adequate if a parent recognizes the importance of physical activity and development, even though the parent identifies as being nonathletic. The nurse's information is adequate if a parent recognizes the value of using "lost" time for learning. The nurse's information is adequate if a parent understands that labeling items will lead to word recognition

A new mother is voicing concern she is breastfeeding her newborn too frequently. How often does the nurse instruct this mother she should expect her newborn to feed? a. Every 2 to 3 hours b. Every 4 to 6 hours c. Every 6 to 8 hours d. Every 8 to 10 hours

ANS: A Breastfed infants may require feedings at 2- to 3-hour intervals because breast milk is more easily digested. A flexible but regular schedule that provides a rest period between feedings is best for the parent and infant.

The nurse observes a 10-month-old infant using her index finger and thumb to pick up pieces of cereal. What does this behavior indicate the infant has developed? a. The pincer grasp b. A grasp reflex c. Prehension ability d. The parachute reflex

ANS: A By 1 year, the pincer-grasp coordination of index finger and thumb is well established.

The nurse is assessing a 1-year-old infant in the pediatric office. What finding should the nurse report to the physician immediately? a. Respiratory rate of 60 breaths/minute b. Pulse rate of 100 beats/minute c. Minimal verbalization d. Fussy behavior

ANS: A Respirations of a 1-year-old infant should be 20 to 40 breaths/minute. Increased respiratory rate can lead to distress and should be reported immediately. Pulse rate of 100 to 140 beats/minute is normal. Minimal verbalization and fussy behavior are not emergency situations or abnormal for this age.

The nurse is talking with a parent about tooth eruption. What teeth will the nurse explain are the first deciduous teeth to erupt? a. Lower central incisors b. Upper central incisors c. Lower lateral incisors d. Upper lateral incisors

ANS: A The first teeth to erupt, usually at about 7 months, are the lower central incisors.

The parent of a 3-month-old infant asks the nurse, "At what age do infants usually begin drinking from a cup?" What is the nurse's most accurate response? a. 5 months b. 9 months c. 1 year d. 2 years

ANS: A The infant can usually drink from a cup when it is offered at about 5 months.

When does the posterior fontanelle close? a. 2 to 3 months b. 3 to 6 months c. 6 to 9 months d. 9 to 12 months

ANS: A The posterior fontanelle closes between 2 and 3 months of age.

The nurse cautions that children who have unmet hunger needs will likely display which characteristic(s)? (Select all that apply.) a. Irritability b. Ineffective feeding patterns c. No predictable sleep-wake cycle d. Distrust e. Effective parent bonding

ANS: A, B, C, D Children who experience frequent hunger do not have effective parental bonding. All other options are probable outcomes for a child who has unmet hunger needs.

The nurse is educating parents of a 2-month-old infant about immunizations. What immunizations against illness should their child receive? (Select all that apply.) a. Pertussis (whooping cough) b. Influenza c. Diphtheria d. Tetanus e. Polio

ANS: A, B, C, D, E The first DPT, polio, and flu immunizations are given at the age of 2 months.

What should the teaching plan include about infant fall precautions? (Select all that apply.) a. Remove all unsteady furniture. b. Keep crib rails up and in locked position. c. Steady infant with hand when on changing table. d. Use tray attachment on high chair as restraint. e. Keep infant seat on the floor while indoors.

ANS: A, B, C, E The tray attachment to a high chair is an inadequate restraint. All other options are good precautions to prevent an infant from a fall.

The nurse is preparing to outline principles of discipline for parents of an infant. What information should the nurse include? (Select all that apply.) a. Firmly say "No." b. Distract the child to another activity. c. Bribe the child with a sweet treat. d. Remain consistent. e. Ignore the child until behavior improves.

ANS: A, B, D Parental approval is important to the infant, and setting limits early is essential. Principles of discipline at this age include the following: lowering the voice to say no firmly, removing the child from the situation, distraction, and consistency.

What will the nurse take into consideration when educating parents regarding infant nutrition? (Select all that apply.) a. Cultural practices b. Sex of the infant c. Parental knowledge d. Infant's developmental level e. Parent-child interaction

ANS: A, C, D, E Parents have many concerns about feeding their infant during the first year of life. This is a period when readiness to receive nutrition education is usually high; therefore, the nurse looks for opportunities to provide accurate information. Assessment of parental knowledge; infant development, behavior, and readiness; parent-child interaction; and cultural and ethnic practices is important. Sex of the infant does not enter into nutritional education.

The nurse is aware that the 7-month-old infant can signal feeding readiness by which action(s)? (Select all that apply.) a. Pulling spoon toward mouth b. Biting at spoon with upper and lower incisors c. Pointing to food bowl d. Bouncing up and down with excitement at sight of food e. Manipulating finger foods

ANS: A, E The 7-month-old infant pulls the spoon toward his or her mouth and can manipulate finger foods. The 7-month-old infant does not have upper incisors and has not developed adequately to recognize the food container or exhibit excitement related to the sight of food.

A parent is concerned because her infant has a diaper rash. What is the best action the nurse would advise the parent to implement? a. Use commercial diaper wipes to clean the area. b. Apply a protective ointment on the area. c. Change the infant's diaper less frequently. d. Keep the diaper area covered all of the time.

ANS: B A protective ointment can be applied when the skin in the diaper area appears pink and irritated.

The nurse discusses child-proofing the home for safety with the mother of a 9-month-old infant. Which statement made by the mother would indicate an unsafe behavior? a. "I put covers on all of the electrical outlets." b. "In the car, she rides in a front-facing car seat." c. "There are locks on all of the cabinets in the house." d. "I have a gate at the top and bottom of the stairs."

ANS: B A rear-facing infant car seat should be used for infants younger than 1 year of age.

16. An infant is hospitalized with RSV bronchiolitis. The priority nursing diagnosis is: a. fatigue related to increased work of breathing. b. ineffective breathing pattern related to airway inflammation and increased secretions. c. risk for fluid volume deficit related to tachypnea and decreased oral intake. d. fear and/or anxiety related to dyspnea and hospitalization.

ANS: B An ineffective breathing pattern is the priority nursing diagnosis for an infant hospitalized with RSV infection.

A parent brings a 6-month-old infant to the pediatric clinic for her well-baby examination. Her birth weight was 8 pounds, 2 ounces. What will the nurse weighing the infant today expect her weight to be? a. At least 12 pounds b. At least 16 pounds c. At least 20 pounds d. At least 24 pounds

ANS: B Birth weight is usually doubled by 6 months of age.

What is the earliest age at which the infant should be able to walk independently? a. 8 to 10 months b. 12 to 15 months c. 15 to 18 months d. 18 to 21 months

ANS: B For the majority of children, the milestone of walking alone is achieved between 12 and 15 months

At what age does an infant's birth weight triple? a. 9 months b. 1 year c. 18 months d. 2 years

ANS: B The infant usually triples his or her birth weight by about 12 months of age.

14. The nurse caring for an infant born at 36 weeks of gestation assesses tremors and a weak cry. The nurse is aware that these are symptoms of: a. respiratory distress syndrome. b. hypoglycemia. c. necrotizing enterocolitis. d. renal failure.

ANS: B The preterm infant, before 38 weeks, should be assessed for hypoglycemia because the infant's glycogen stores are not adequate.

Parents of a 6-month-old infant ask the nurse why it is necessary to offer iron-rich formula to their child. What is the correct response? a. "The infant has limited ability to produce red blood cells." b. "The infant has ineffective digestive enzymes." c. "The infant has exhausted maternal iron stores." d. "The infant has need of the iron to support dentition."

ANS: C

5. The nurse auscultating breath sounds of an infant with respiratory syncytial virus would immediately report the assessment of: a. respiration rate decrease from 40 to 32 breaths/min. b. heart rate decrease from 110 to 100 beats/min. c. "quiet chest" from previous assessment of wheezing. d. oxygen saturation of 90%.

ANS: C A "quiet chest" after assessment of wheezing indicates occlusion of air pathways and impending respiratory arrest. All other options are within normal range for infants undergoing oxygen administration.

The mother of an infant born prematurely tells the nurse, "The baby is irritable. She cries during diaper changes and feedings. Can you make some suggestions about what I should do to soothe her?" What is the most appropriate recommendation to help this parent? a. Play the radio or TV while you feed the infant. b. Put the infant in a room with sunlight. c. Wrap the infant snugly when you hold them. d. Change the infant's position quickly.

ANS: C A strategy that may be helpful is to swaddle the infant snugly in a light blanket with extremities flexed and hands near the face.

What would the nurse expect a 4-month-old infant to be able to accomplish? a. Hold a cup. b. Stand with assistance. c. Lift head and shoulders. d. Sit with back straight.

ANS: C Because development is cephalocaudal, of these choices, lifting the head and shoulders is the one that the infant learns to do first. The infant can usually sit with support at about 5 months of age and can sit alone at about 8 months.

What is the most appropriate activity to recommend to parents to promote sensorimotor stimulation for a 1-year-old infant? a. Ride a tricycle. b. Spend time in an infant swing. c. Play with push-pull toys. d. Read large picture books.

ANS: C Push-pull toys are appropriate to promote sensorimotor stimulation for a 1-year-old infant

An infant with bronchiolitis is hospitalized. The causative organism is respiratory syncytial virus (RSV). The nurse knows that a child infected with this virus requires the following isolation: a. reverse isolation. b. airborne isolation. c. Contact Precautions. d. Standard Precautions.

ANS: C RSV is transmitted through droplets. In addition to Standard Precautions and hand washing, Contact Precautions are required. Caregivers must use gloves and gowns when entering the room. Care is taken not to touch their own eyes or mucous membranes with a contaminated gloved hand. Children are placed in a private room or in a room with other children with RSV infections. Reverse isolation focuses on keeping bacteria away from the infant. With RSV, other children need to be protected from exposure to the virus. The virus is not airborne.

The nurse is assessing development in a 9-month-old infant. What would the nurse expect to observe? a. Speaking in 2-word sentences b. Grasping objects with palmar grasp c. Creeping along the floor d. Beginning to use a spoon rather sloppily

ANS: C The 9-month-old infant tries to creep, has developed pincer movement, and can grasp a spoon without keeping food on it.

What is the earliest age at which an infant is able to sit steadily alone? a. 4 months b. 5 months c. 8 months d. 15 months

ANS: C The infant can sit alone without support at about 8 months of age.

What is an abnormal finding in an evaluation of growth and development for a 6-month-old infant? a. Weight gain of 4 to 7 ounces per week b. Length increase of 1 inch in 2 months c. Head lag present d. Can sit alone for a few seconds

ANS: C The infant should be holding the head up well by 5 months of age. If head lag is present at 6 months, the child should undergo further evaluation.

Which statement indicates the mother of an 8-month-old infant understands infant sleep patterns? a. "I put the baby in my bed until she falls asleep, then I put her in her crib." b. "I let the baby skip an afternoon nap so that she will fall asleep earlier." c. "I put the pacifier in the crib so that she can find it when she wakes up." d. "I rock the baby back to sleep if she wakes up at night."

ANS: C The parent should assist the infant to develop self-soothing behaviors so that the infant can get back to sleep on her own

What statement made by a parent indicates correct understanding of infant feeding? a. "I've been mixing rice cereal and formula in the baby's bottle." b. "I switched the baby to low-fat milk at 9 months." c. "The baby really likes little pieces of chocolate." d. "I give the baby new foods before he takes his bottle."

ANS: D New solid foods should be introduced before formula or breast milk to encourage the infant to try new foods.

A mother calls the pediatrician's office because her infant is "colicky." What is the most helpful measure the nurse can suggest to the mother? a. Sing songs to the infant in a soft voice. b. Place the infant in a well-lit room. c. Walk around and massage the infant's back. d. Rock the fussy infant slowly and gently.

ANS: D One technique the nurse can offer parents of a fussy infant is to rock the infant gently and slowly while being careful to avoid sudden movements.

What will the nurse advise a parent to do when introducing solid foods? a. Begin with one tablespoon of food. b. Mix foods together. c. Eliminate a refused food from the diet. d. Introduce each new food 4 to 7 days apart.

ANS: D Only one new food is offered in a 4- to 7-day period to determine tolerance.

A mother is concerned because her 10-month-old infant is lethargic. What is the best action the nurse can advise this mother to implement? a. Keep the infant's room well lit. b. Rub the infant's soles vigorously. c. Offer the infant a pacifier. d. Handle the infant slowly and gently.

ANS: D Some infants respond to stimulating environments by shutting down. Move and handle infants slowly and gently.

How might the nurse demonstrate the parachute reflex with an infant? a. Lifting the infant high in the air above her head b. Holding the infant in a football hold, cradling the head c. Seating the infant in a stroller in an upright position d. Placing the infant downward into the crib

ANS: D The infant, when placed downward in a prone position, will protectively extend the arms.

4. The nurse carefully assesses the preterm infant for respiratory distress syndrome because of a deficiency of: a. protein. b. estrogen. c. hyaline. d. surfactant.

ANS: D The production of surfactant, necessary for the absorption of oxygen by the lungs, is deficient in the preterm infant.

Parents of an infant inform the nurse they are planning home preparation of solid foods. What directions should the nurse provide? (Select all that apply.) a. Boil foods in a large amount of water. b. Do not freeze foods. c. Add 1 teaspoon of salt per cup. d. Puree food in electric blender. e. Add sugar sparingly.

ANS: D, E Home-prepared infant food can be strained and pureed in an electric blender. Sugar should be added sparingly. Food should be boiled in small amounts of water and not over cooked to avoid destroying nutrients. Foods may be frozen in ice cube trays and defrosted for use.

A neonate experiences meconium aspiration at the time of delivery and develops respiratory distress syndrome (RDS). Which nursing diagnosis would be most appropriate for an infant diagnosed with this disorder? A. Risk for Infection B. Risk for Aspiration C. Impaired Gas Exchange D. Dysfunctional Ventilatory Weaning Response

Answer: C Rationale: Impaired gas exchange is the most appropriate nursing diagnosis because meconium aspiration interferes with the exchange of O2 and CO2. Risk for infection is present but is not as high a priority as impaired gas exchange. Risk for aspiration has already occurred. Dysfunctional ventilatory weaning response may be appropriate i the newborn demonstrates difficulty with the ventilatory weaning process

Compared with an infant born vaginally an infant born via cesarean section is more likely to manifest which condition? A. crib death syndrome B. neurological deficits C. failure to thrive syndrome D. Respiratory distress syndrome

Answer: D Rationale: Research has shown that respiratory distress syndrome (RDS) is more common in infants born by cesarean birth without labor than in those born vaginally. The other answer options A, B, and C are not associated with cesarean births

the nurse is planning care for a child admitted to the pediatric unit with neonatal bronchopulmonary dysplasia. which intervention should the nurse perform first a. keep fluids at a minimum b. provide humidified oxygen c. give palivizumab vaccine d. keep ambient air temperature cooler than normal

B (liquify secretions)

Which care safety device should be used for a child who is 8yrs old and 4ft tall? A - seat belt B - booster seat C - rear-facing convertible seat D - front-facing convertible seat

B - booster seat

infants with neonatal bronchopulmonary dysplasia require frequent, prolonged rest periods. which sign indicates over-stimulation a. increased alertness b. good eye contact c. cyanosis d. increased appetite

C

The mother of an 8yr old child tells the clinic nurse that she is concerned about the child because the child seems to be more attentive to friends than anything else. Using Erikson's psychosocial development theory, the nurse should make which response? A - "you need to be concerned" B - "you need to monitor the child's behavior closely" C - "at this age, the child is developing this own personality" D - "you need to provide more praise to the child to stop this behavior"

C - "at this age, the child is developing this own personality"

According to Piaget's theory, the period of cognitive development in which the child is able to distinguish between concepts related to fact and fantasy, such as human beings are incapable of flying like birds is the ___ period of cognitive development A - sensorimotor B - formal operations C - concrete operations D - preoperational

C - concrete operations

A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. The nurse's assessment of this data is: The infant is at low risk for congenital anomalies. The infant is at high risk for intrauterine growth retardation. The infant is at high risk for respiratory distress syndrome. The infant is at high risk for birth trauma.

C: The infant is at high risk for respiratory distress syndrome.

a child is newly diagnosed with neonatal bronchopulmonary dysplasia. which intervention should the nurse perform first to help the parents a. teach cardiopulmonary resuscitation b. refer them to support groups c. help parents id necessary lifestyle changes d. evaluate and assess parents' stress and anxiety levels

D

the nurse is preparing a care plan for the parents of a child with neonatal bronchopulmonary dysplasia. which outocme would the nurse anticipate for this childs parents a.report the same level of stress b. make safe decisions with professional assistance c. participate in routine caretaking activities d. verbalize the causes, risks, therapy options and nursing care

D

the nurse is educating the parent of a 2yo with neonatal bronchopulmonary dysplasia who is placed on futosemide. which statement by the parents best indicates an understanding of this medication a. i need to make sure my child uses the bathroom at least every 6 hours b. i need to make sure m child gets his blood pressure checked twice a year c. i need to make sure my child wears short sleeves when outside d. i need to make sure my child eats foods rich in potassium

D (should eat foods rich in potassium to replace what is lost through diuresis while taking furosemide)

The mother of an infant diagnosed with bronchiolitis asks the nurse what causes this disease. The nurse's response would be based on the knowledge that the majority of infections that cause bronchiolitis are a result of:

RSV

Which of the following interventions is most appropriate for helping parents to cope with a child newly diagnosed with bronchopulmonary dysplasia? a. Teach cardiopulmonary resuscitation b. Refer them to support groups c. Help parents identify necessary lifestyle changes d. Evaluate and assess parents; stress and anxiety levels

a. Teach cardiopulmonary resuscitation

Which of the following symptoms is seen in a child with bronchopulmonary dysplasia? a. Minimal work of breathing b. Tachypnea and dyspnea c. Easily consolable d. Hypotension

b. Tachypnea and dyspnea

which neonate is at highest risk for developing neonatal bronchopulmonary dysplasia a. a neonate born at 38 weeks receiving 1-4L of O2 during feedings b. a premature neonate born at 34 weeks receiving supplemental oxygen c. a premature neonate born at 28 weeks on a high pressure ventilator d. a neonate born at 42 weeks who requires treatments for respiratory syncytial

c (neonate less than 30 weeks)

which nursing intervention is the priority for an infant with neonatal bronchopulmonary dysplasia a. weight the infant on the same scale, at the same time each day b. give the infant higher calorie formula as ordered c. monitor oxygen status via pulse ox d. monitor strict I & O

c (priority)

Infants with bronchopulmonary dysplasia are commonly treated with bronchodilators such as theophylline. Which of the following adverse effects is common with this drug? a. Lethargy b. Decreased calcium level c. Increased heart rate d. Decreased serum potassium level

c. Increased heart rate

When does the anterior fontanelle close? a. 2 to 3 months b. 3 to 6 months c. 6 to 9 months d. 12 to 18 months

d. 12 to 18 months

Of all the signs seen in infants with respiratory distress syndrome, which sign is especially indicative of the syndrome?

grunting

The most important reason to protect the preterm infant from cold stress is that:

it could make respiratory distress syndrome worse.