Evolve: Infant
After a cleft lip repair a nurse places elbow restraints on the infant. The parents ask the nurse, "Why does our son have to have restraints?" How should the nurse respond?
"Because we're keeping the arms straight your baby won't be able to touch his mouth."
Which statement by the parents of an infant with Erb palsy indicates to the nurse that they have an accurate understanding of their infant's prognosis?
"Complete recovery takes a few months."
An infant with a diagnosis of heart failure is being given furosemide (Lasix) twice a day. Which laboratory value should the nurse report to the health care provider?
Potassium of 3.0 mEq/L
What is the priority nursing action for an infant after the surgical repair of a cleft lip?
Preventing crying
A nurse in the pediatric clinic is teaching a mother how to care for her infant who has eczema. What is most important for the nurse to teach the mother?
Preventing secondary infections
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?
"Electrical activity in the baby's heart is recorded, then printed on graph paper."
An infant has been admitted with failure to thrive (FTT). The nurse knows that more education is required when she hears one of the parents say:
"I can double the amount of water in the formula to save money."
A father calls the clinic because he wants information about how to care for his child's severe diaper rash. The nurse asks the father what he has been doing so far and determines that the father needs further teaching when he says:
"I direct a heat lamp at the buttocks."
A nurse is teaching skin and basic care to the mother of a 6-month-old infant with eczema. Which statement indicates that the mother needs further teaching?
"I'll have to be careful not to cut my baby's nails short."
The nurse provides nutritional counseling to the parents of a 6-month-old formula-fed infant who will begin eating solid foods. Which statement by a parent indicates understanding of the nurse's advice?
"I'll keep give him formula instead of regular cow's milk."
The parents of a 6-month-old ask a nurse how to introduce their infant to pureed foods. How should the nurse respond?
"Introduce one food at a time every 4 to 7 days."
A new mother is concerned that her 1-month-old infant is nursing every 2 hours. Which response by the nurse is most appropriate?
"It's common for newborns to nurse this often. Let's talk about how you're adjusting with the new baby."
A mother who is visiting the pediatric clinic with her 10-month-old son tells the nurse how pleased she is with her chubby infant. She exclaims, "Look how much weight he's gained even though he drinks only orange juice! He won't drink any milk!" What is best response by the nurse.
"Let's talk about his nutrition."
The nurse knows that additional discharge instructions are needed for parents whose infant has just undergone corrective surgery for cleft palate when the mother says:
"Lying on the abdomen is prohibited, so we'll keep him in an infant seat."
While discussing immunizations with the nurse, the father of a 7-month-old boy states, "You know, my son doesn't sit up by himself yet. Shouldn't he be able to do this by now?" How should the nurse respond?
"Many babies don't sit up until they're 8 months old. Let's watch what he does when I sit him up."
The parent of a newborn asks a nurse why, except for hepatitis B vaccine, the immunization schedule does not start until the infant is 2 months old. How should the nurse respond?
"Maternal antibodies interfere with the development of active antibodies by the infant when immunized."
A nurse is teaching parenting to a group of teenage mothers. After a discussion of child safety, the young mothers provide feedback. Which comment indicates the need for additional information?
"My baby could drown if I leave her alone in water higher than her waist."
The parents of an infant ask the nurse why their baby is scheduled to receive the intramuscular polio vaccine rather than the oral vaccine. What is the best response by the nurse?
"The American Academy of Pediatrics recommends the intramuscular vaccine because it is safer."
A 5-month-old infant experiences severe diarrhea and is given intravenous fluids. What is the most important reason for the nurse to closely monitor the IV flow rate?
Prevention of cardiac overload
What should the nursing care of an 8-month-old infant with tetralogy of Fallot include?
Prevention of increased respiratory effort to promote oxygenation
An infant is found to have hydrocephalus. Which finding alerts the nurse to suspect increasing intracranial pressure?
Projectile vomiting
A nurse in the pediatric clinic receives a call from the mother of a 12-month-old infant who has had a fever, runny nose, cough, and white spots in the mouth for 3 days. A rash started on the face and has now spread to the entire body. Which communicable infection does the nurse suspect?
Rubeola
The parents of an infant who is to undergo insertion of a right ventriculoperitoneal shunt for hydrocephalus are taught about postoperative positioning that helps prevent pressure on the valve site. What statement indicates that they understand the teaching?
"The flat left side-lying position is the safest position for our baby."
An infant is found to have communicating hydrocephalus. The parents ask for clarification of the health care provider's explanation of the problem. How should the nurse respond?
"There is a part of the brain surface that usually absorbs spinal fluid after its production that is not functioning adequately."
The mother of an infant with hypertrophic pyloric stenosis states that she has never heard of this disorder and asks many questions. What should the nurse emphasize when responding?
"This disorder has an excellent prognosis."
A new father tells a nurse that his sister and her family plan to visit the new baby and that his niece and nephew have just recovered from chickenpox (varicella). Their lesions are completely healed or have scabs and are no longer draining. He asks the nurse whether it is safe for them to be near the baby. What is the best response by the nurse?
"The most contagious time is before the spots appear. It'll be safe to visit."
An infant who was in a motor vehicle collision has undergone open repair of a fractured sternum and now has a chest tube. What should the nurse explain to the infant's parents about the chest tube?
"The tube has been placed to drain the air that entered the chest cavity during surgery."
It is suspected that a 5-week-old infant has pulmonic stenosis, and cardiac catheterization is scheduled. When the parents ask what the test involves, the nurse replies:
"A catheter will be inserted into a blood vessel in your baby's groin and then threaded to the heart to confirm an anatomic abnormality."
The mother of a 7-month-old infant who becomes irritable when teething tells the nurse, "My aunt said to wipe my baby's gums with wine to ease the pain." What is the best response by the nurse?
"An over-the-counter topical gel can be used, but make sure it's for teething."
Phenobarbital is prescribed for an infant who has had repeated seizures. One week later, at the follow-up visit, the infant is lethargic and the mother states that the infant is sleeping excessively. The infant's mother asks the nurse what is happening to her baby. What should the nurse tell the mother?
"This is a response to the medication that will subside eventually."
A mother whose infant was found to have cerebral palsy at 6 months of age asks why she was not told that her baby had cerebral palsy when the infant was born. How should the nurse respond?
"Until there's control of voluntary movement a diagnosis can't be confirmed."
The mother of a 5-month-old boy calls the nurse in the pediatric clinic to ask why her son no longer turns his head toward her breast when she touches his cheek. How should the nurse respond?
"Usually this reflex disappears around 4 months."
An intravenous line is inserted in the scalp vein of an infant. The mother asks why the IV is not placed in the hand or arm as for an adult. How should the nurse respond?
"Usually veins in the arm or hand are used, but your baby's were too small."
A parent asks the nurse, "The doctor said my baby has something called pulmonic stenosis. What does that mean?" What is the best response by the nurse?
"What else did the doctor say?"
Ferrous fumarate (Feostat) 30 mg is prescribed for an infant. The ferrous fumarate solution contains 45 mg/0.6 mL. How much solution should the nurse administer? Include a leading zero if applicable. Record your answer using one decimal place. _____ mL
0.4 ml
What is the priority nursing intervention for an infant with a myelomeningocele before surgical correction?
1
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.)
1 Playing peek-a-boo 2 Turning completely over 3 Reaching to be picked up 5 Sitting for a short time without support
An infant is to receive an intravenous antibiotic as a piggyback. The prescription is 10 mg/kg body weight/24 hr, to be administered in equal doses every 12 hours. The infant weighs 22 lb. How many milligrams of the antibiotic should the infant receive per dose? Record your answer using a whole number. ___ mg
100 mg/day
A nurse is teaching a mother about the immunization schedule for her baby. Between which months of age should the measles vaccine be given?
12 and 15
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:
13 to 18 months of age
A nurse is caring for a severely dehydrated infant. After adequate kidney function is confirmed, potassium is added to the intravenous rehydration solution. It is to be infused at a rate of 15 mL/kg body weight every 24 hours. The infant weighs 13 lb. What does the nurse calculate for the infant's intravenous fluid intake per day? Record your answer using a whole number. __________ mL
13/2.2 = 5.9. 15 × 5.9 = 88.5 mL rounded up equals 89 mL/24 hours
What is the priority of preoperative nursing care for an infant with a cleft lip?
17
A nurse provides clapping, percussion, and postural drainage every 4 hours for a 3-month-old infant with cystic fibrosis. When is the best time for the nurse to schedule chest physiotherapy?
2 hours after feedings
An infant is receiving 22 mL/hr intravenous fluid by way of an infusion pump. How much fluid will be infused between 8 am and 8 pm? Record your answer using a whole number. __________ mL
22 mL × 12 h = 264 mL
A 6-month-old infant weighing 15 lb is admitted with a diagnosis of dehydration. A prescription for oral rehydration therapy 4 mL/kg Pedialyte over 4 hours is made. What is the approximate amount of fluid that the infant should ingest during the 4 hours?
28 mL -At 15 lb the infant weighs about 7 kg; 4 mL × 7 kg is 28 mL. The other amounts (32 mL, 38 mL, 42 mL) are too much.
A nurse evaluating a 1-year-old infant's hematocrit reading compares it with the expected hematocrit range for this age group. What is the hematocrit of a healthy12-month-old infant?
29% to 41%
A nurse at the well-child clinic determines a 1-year-old infant's length to be below what is expected. The current height is 28 inches, and the birth length was 20 inches. What should this infant's current length be? Record your answer using a whole number. __________ inches
30 inches.
A gavage feeding is prescribed for an infant. How does the nurse determine the length of tube needed to reach the stomach?
A measurement is made from earlobe to nose and then to the epigastric area.
A 2-month-old infant is to have a nasogastric tube inserted. The nurse expects that:
A pacifier will be offered to lessen gagging and allow easier insertion of the tube
The parents of an infant born with a myelomeningocele are confused about what the health care provider has told them about the condition. What should the nurse consider before answering the parents' questions in language that they will understand?
A saclike cyst of meninges, containing a portion of spinal cord and fluid, is protruding through a defect in the spine.
A nurse is caring for an infant with developmental dysplasia of the hip. What is the priority intervention for this child?
Abduction of the hip
A nurse is caring for an infant with a myelomeningocele. What does the nurse expect this infant to have that differentiates it from an infant with a meningocele?
Affected lower extremities
The parents of a boy born with hypospadias ask the nurse at what age the repair of this congenital defect is performed. What is the most appropriate response by the nurse?
After 6 months and before 1 year of age
A severely dehydrated infant with gastroenteritis is admitted to the pediatric unit. Nothing-by-mouth (NPO) status is prescribed. The parents ask why their baby cannot be fed. The nurse explains that this is necessary to:
Allow the intestinal tract to rest
A mother of three children, who was abandoned by her husband shortly after the birth of her youngest child, brings her daughter, now 9 months old, to the pediatric clinic. The infant is found to have nonorganic failure to thrive and is admitted to the hospital. What infant behavior does the nurse anticipate as the mother leaves to return home to care for her other children?
Allowing the nurse to take her but remaining stiff while being held
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?
Altered fluid intake before surgery
A nurse in the pediatric clinic is reviewing the chart of a 1-year-old infant before the examination. The infant's birthweight was 7 lb 8 oz. What weight should the nurse expect the infant to be at 1 year of age? Record your answer rounding to one decimal place. __________ lb
An infant's birthweight should triple by 1 year of age; therefore 7.5 lb × 3 = 22.5 lb.
The parents of a 6-week-old infant who was born without an immune system ask the nurse why their baby is still so healthy. What is the best response by the nurse?
Antibodies are passively received from the mother through the placenta and breast milk.
What is the priority nursing action when a 3-month-old infant is receiving intravenous (IV) fluids by way of an antecubital vein?
Applying arm boards to prevent bending at the elbows
The nurse notes that a 6-month-old infant is startled by a loud noise but does not turn in the direction of the sound. How should the nurse interpret this response?
As evidence of hearing loss
A newborn has been found to have with developmental dysplasia of the hips and is placed in a Pavlik harness. The parents have been instructed that the infant is to wear the appliance full time except for bathing. What additional instruction should the nurse give the parents about the harness?
Avoid using the legs to lift the infant's buttocks when changing the diaper at bathtime.
A parent of a 6-month-old infant asks the nurse which foods should be introduced first. What is the best response by the nurse?
Baby cereals
A nurse discusses with a group of parents in the well-baby clinic the appropriate car restraints to be used for children. The nurse determines that one of the parents understands the teaching about car restraints for newborns when the parent says that infants should be buckled into an infant car seat and that the car seat must be in the:
Back seat, facing backward
The nurse is caring for a group of patients who require various interventions. What patient care may be delegated to unlicensed assistive personnel (UAP)?
Bathing a child with an intravenous line and a PCA pump
According to Piaget's theory of cognitive development, what should the nurse expect a 6-month-old infant to demonstrate?
Beginning of object permanence
A nurse is teaching a parent about the behaviors that are first evident in an infant at 8 months of age. What should the nurse include? (Select all that apply.)
Being shy with strangers Showing interest in small objects
The parents of a 5-month-old infant tell a nurse at the well-baby clinic that they are concerned because their baby weighs only 14 lb. After reviewing the infant's health history, the nurse assures them that their baby's weight is within the expected range for age. What information prompted this reply?
Birthweight
An infant with a cleft lip is fed with a special nipple. What should the nurse teach the parents about feeding their infant to minimize regurgitation?
Burp frequently during a feeding
A nurse is caring for an infant with hydrocephalus after the insertion of a shunt. How should the nurse evaluate the effectiveness of the shunt?
By palpating the anterior fontanel
A 2-month-old infant with the diagnosis of heart failure is discharged with a prescription for oral digoxin (Lanoxin) 0.05 mg every 12 hours. The bottle of digoxin is labeled "0.05 mg/mL." Which item should the nurse teach the mother to use when administering the medication?
Calibrated syringe
An infant is receiving the first diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) at 2 months of age. What instructions should the nurse give the parents?
Call the clinic if marked drowsiness occurs.
The mother of a healthy 10-month-old infant asks the nurse what type of milk and puréed foods she should give her baby. What is the best response by the nurse?
Carrots, chicken, applesauce, and breast milk
A nurse is caring for a 9-month-old infant with gluten-induced enteropathy. What common term for this disorder should the nurse use when discussing the infant's diagnosis with the parents?
Celiac disease
At 20 hours of age a newborn is found to have a bilirubin concentration of 13 mg/dL. Which finding most likely contributed to this bilirubin level?
Cephalhematoma
An infant is admitted to the pediatric unit with gastroenteritis and dehydration. The nurse determines that the parents understand the teaching about contact precautions when they note that after washing their hands they need to:
Change their gloves each time they change the baby's diaper
A 3-week-old infant has surgery for esophageal atresia. What is the immediate postoperative nursing care priority for this infant?
Checking the patency of the nasogastric tube
What behavior does the nurse anticipate while feeding a newborn with choanal atresia?
Chokes on the feeding
A parent brings a 2-month-old infant with Down syndrome to the pediatric clinic for a physical and administration of immunizations. Which clinical finding should prompt the nurse to have further assessment by the care provider?
Circumoral cyanosis
A 3-month-old infant hospitalized with severe diarrhea has excoriated skin in the diaper area. The mother becomes concerned when she discovers that the nurse has left her infant without a diaper. What is the nurse's explanation for this action?
Cleansing of the skin followed by air-drying reduces excoriation
At the age of 3 weeks an infant undergoes surgery to repair a cleft lip. Postoperative nursing care should include:
Cleansing the suture line to prevent infection
What clinical manifestation of tetralogy of Fallot should the nurse expect when caring for an infant with this diagnosis?
Clubbing of fingers
A 3-month-old infant has been hospitalized with respiratory syncytial virus (RSV). What is the priority intervention?
Clustering care to conserve energy
A nurse is caring for a 3-month-old infant with congenital hypothyroidism. What should the parents be taught about the probable effect of the condition on the infant's future if treatment is not begun immediately?
Cognitive impairment
A mother brings her 9-month-old infant to the clinic. The nurse is familiar with the mother's culture and knows that belly binding to prevent extrusion of the umbilicus is a common practice. The nurse accepts the mother's cultural beliefs but is concerned for the infant's safety. What variation of belly binding does the nurse discourage?
Coin in the umbilicus
A nurse is caring for an infant with Down syndrome. What does the nurse recall as the most common serious anomaly associated with this disorder?
Congenital heart disease
An infant vomits after feedings and starts to lose weight. Galactosemia is diagnosed. The nurse explains to the parents that galactosemia is an inherited autosomal recessive disorder that results in an:
Error in carbohydrate metabolism
A nurse is caring for a 4-week-old infant with hypertrophic pyloric stenosis who has been admitted to the child health unit for corrective surgery. What is the primary objective of preoperative care for this infant?
Correcting fluid and electrolyte imbalances
A nurse is caring for a newborn with a diaphragmatic hernia and impaired gas exchange. What does the nurse identify as the cause of the infant's decreased gas exchange?
Decreased oxygen intake
What common finding can the nurse identify in most children with symptomatic cardiac malformations?
Delayed physical growth
An infant is born with exstrophy of the bladder. The parents are concerned and confused when they are told that their infant will need surgery. What nursing intervention will best help the infant's parents?
Demonstrating the same manner of care for the infant as for other infants on the unit
A nurse is caring for a 9-month-old infant who has been admitted to the pediatric unit with a tentative diagnosis of meningitis. A lumbar puncture is performed. The nurse explains to the parents that the primary reason this procedure is performed is to:
Determine the causative agent
What is the nurse's priority concern when caring for an infant born with exstrophy of the bladder?
Development of an infection
The neonate has a protruding tongue and a crease that transverses the entire width of each palm. The nurse recognizes that these findings are characteristic of what congenital condition?
Down syndrome
A nurse is caring for an infant who has undergone myringotomy because of recurrent otitis media. What does the nurse expect to note when providing care to this child?
Drainage into the external auditory canal
A cast is applied to the involved extremity of an infant with talipes equinovarus (clubfoot). The nurse tells the parents that they will have to bring their baby back to the clinic for a cast change:
Each week
A nurse counsels the mother of an 8-month-old infant to be sure that the floors are free of small objects when her child is crawling. What is the rationale for this instruction?
Eight-month-old infants pick up small objects and place them in their mouths.
What action should be included in the nursing care of an infant with increased intracranial pressure?
Elevating the head higher than the hips
An infant who is exhibiting signs of increased intracranial pressure (ICP) is admitted to the pediatric intensive care unit. What care should the nurse implement that is specific for this infant's condition?
Elevating the infant's head higher than the hips
A 1-day-old infant with an imperforate anus undergoes a pull-through procedure with an anoplasty. What should postoperative nursing care include?
Encouraging continuation of breastfeeding
What is the best intervention of the nurse to help foster the development of a trusting parent-child relationship?
Encouraging face-to-face contact between the parents and infant
An infant with a myelomeningocele is scheduled for surgery to close the defect. Which nursing action best facilitates the parent-child relationship in the preoperative period?
Encouraging the parents to stroke their infant
Which nursing intervention provides the most support to the parents of an infant with an obvious physical anomaly?
Encouraging them to express their concerns
What is the best way for the nurse to promote the social development of a 9-month-old infant?
Engaging in peek-a-boo
An infant who has undergone cardiac surgery for a congenital defect is to be discharged. What should the nurse emphasize to the parents regarding administration of the prescribed antibiotic?
Ensure that the antibiotic is administered as prescribed.
What should be included in the plan of care for a newborn with hypospadias before corrective surgery is performed?
Explaining to the parents why a circumcision is not done
A mother whose infant is born with talipes equinovarus (clubfoot) tells the nurse that she is afraid to have more children because they might have the same problem. What is the best response by the nurse?
Exploring the mother's understanding of the probable causes of this disorder
An infant has a plaster cast applied for clubfoot correction. What nursing intervention will hasten drying of the cast?
Exposing the casted extremity
What feeding instruction should a nurse give the mother of a 2-month-old infant with the diagnosis of heart failure?
Feed slowly while allowing time for adequate periods of rest.
A nurse is caring for a 1-month-old infant who has undergone surgery to repair a cleft lip. What should the nurse use to facilitate feeding during the immediate postoperative period?
Feeding syringe
A nurse is discussing an infant's diet with a mother who is breastfeeding. Why should the nurse recommend that the infant be offered solid foods by 5 or 6 months of age? (Select all that apply.)
Fetal iron reserves are depleted. Food can be taken from a spoon.
An infant who underwent revision of a ventriculoperitoneal shunt is found to have meningitis, the result of an infected shunt. What clinical manifestations support this conclusion? (Select all that apply.)
Fever Stiff neck Poor feeding
During change-of-shift report, the oncoming nurse receives information about a 14-month-old infant who underwent cleft palate repair the previous day. The child is currently on a full-liquid diet from cups only. No spoons or straws are allowed in the child's mouth. In addition, the child has elbow restraints on both arms. What care should the nurse include during the course of the shift?
Finishing each meal with a drink of water
A nurse explains to the parents of a newborn with developmental dysplasia of the hip (DDH) that the infant most likely will be:
Fitted with a Pavlik harness
The mother of a 5-month-old infant with heart failure questions the necessity of weighing her baby every morning. The nurse's response is based on the fact that this daily information is important in determining:
Fluid retention
A 2-month-old infant is admitted to the pediatric unit for observation after an automobile collision. Family members are unable to stay. How can the nurse best provide psychological comfort for the infant?
Following a routine to which the infant is accustomed
For how long should a nurse maintain isolation of a child with bacterial meningitis?
For 48 hours after antibiotic therapy begins
During discharge planning the parents of an infant with spina bifida express concern about skin care and ask the nurse what can be done to avoid problems. What is the best response by the nurse?
Frequent diaper changes with cleansing are needed.
A nurse has just administered an immunization injection to a 2-month-old infant. What instructions should the nurse give the parent if the infant has a reaction?
Give acetaminophen for fever; call the health care provider if the child exhibits marked drowsiness or seizures.
A 10-month-old boy is in a restaurant with his parents and grandparents. The grandfather places several pieces of bread on the high chair tray for the infant. A nurse sitting nearby sees the infant gag and become red-faced, then turn cyanotic. With permission from the family, the nurse holds the child with the head downward and:
Gives the infant five back blows
A pale, lethargic 1-year-old infant weighs 28 lb (12.6 kg) and has a hemoglobin level of 9 g/dL. The parent tells the nurse that the infant refuses solid food when it is offered by spoon and drinks between four and six full bottles of milk per day. What should the nurse recommend?
Giving the infant finger foods such as dry cereal and chopped meat
What behavior does the nurse expect a healthy 5-month-old infant to exhibit?
Grasping objects voluntarily
Which observation during a developmental appraisal of a 6-month-old infant is most important to the nurse in light of a diagnosis of hydrocephalus?
Head lag
A 4-month-old infant is to receive the second diphtheria/tetanus/pertussis (DTaP) immunization. The nurse reviews the infant's medical history before administering the vaccine. What information in the infant's history will influence the decision whether to administer the vaccine?
High fever after the first dose
A nurse is trying to soothe a 2-month-old infant who is crying. What is the best way to soothe a young infant?
Holding and rocking the infant in a quiet room
How can a nurse best soothe a hospitalized infant who appears to be in pain?
Holding the infant
An infant is being admitted with bacterial meningitis. The nurse knows the priority nursing action is:
Implementing respiratory isolation precautions
At Children's Hospital, infants are usually transported to x-ray in their parent's arms. After admission to the hospital for an upper respiratory infection, a 3-month-old infant is scheduled for a chest x-ray. The baby's mother is also sick and unable to go with the infant to the x-ray department. What manner of transportation should the nurse use to transport the infant to the x-ray department?
In the child's stroller
A 6-week-old infant and his mother arrive in the emergency department in an ambulance. The father arrives several minutes later with two children, 7 and 9 years old. The infant is not breathing, and the eventual diagnosis is sudden infant death syndrome (SIDS). The parents take turns holding the infant in another room. The nurse remains present and provides emotional support to the parents. What is an important short-term goal for this family?
Including the infant's siblings in the events and grieving in the wake of the infant's death
A nurse teaches the parents of an infant with a cardiac defect how to detect impending heart failure. What should the parents be taught to identify as an early sign?
Increased heart rate
An infant who has a congenital heart defect with left-to-right shunting of blood is admitted to the pediatric unit. What early sign of heart failure should the nurse identify?
Increased respiratory rate
A dehydrated infant with a several-day history of vomiting is admitted to the pediatric unit with the diagnosis of gastroenteritis. The nurse plans to monitor the infant's response to parenteral therapy. What is the best indicator of rehydration?
Increased weight
An infant is found to have developmental dysplasia of the hip (DDH) 6 weeks after birth. The parents ask a nurse at the clinic why their infant must be restrained in a harness at such an early age. How should the nurse respond?
Infants' hip joints are cartilaginous, allowing molding of the acetabulum.
An infant is admitted to the pediatric unit with bronchiolitis caused by respiratory syncytial virus (RSV). What interventions are appropriate nursing care for the infant? (Select all that apply.)
Instilling saline nose drops Maintaining contact precautions Suctioning mucus with a bulb syringe
A mother tells the nurse that her 7-month-old infant has just started sitting without support. The nurse teaches the mother that this:
Is expected developmental behavior at this age
After a discussion with the health care 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?
It is a connection between the pulmonary artery and the aorta.
A parent brings a 2-week-old infant to the clinic because the infant continually regurgitates. Chalasia, an incompetent cardiac sphincter, is suspected. What instructions should the nurse give the parent?
Keep the infant in an upright position after feedings.
A nurse is caring for an infant born with a myelomeningocele who is scheduled for surgery. What is the priority preoperative goal for this infant?
Keeping the infant infection free
An infant with Tetralogy of Fallot becomes cyanotic and dyspneic after a crying episode. In what position should the nurse place the infant to relieve the cyanosis and dyspnea?
Knee-chest
What characteristics does a nurse expect infants and young children with failure to thrive to exhibit? (Select all that apply.)
Language deficit Tendency to illness
A nurse is selecting toys for a 5-month-old infant. Which toy should not be given to the infant?
Large snap beads
A 1-year-old infant with a distended abdomen is admitted to the pediatric unit with the diagnosis of Hirschsprung disease. In which position should the nurse place the infant?
Lateral
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 the health care provider to identify during the physical assessment?
Limited abduction of the affected hip
Before administering the first series of immunizations to a 2-month-old infant, the nurse tells the mother that reactions may occur. What are the characteristics of these reactions?
Local or systemic and usually mild
A nurse is caring for an infant with phenylketonuria. What diet should the nurse anticipate will be prescribed by the health care provider?
Low-phenylalanine
A 6-month-old infant is brought to the emergency department in severe respiratory distress. A diagnosis of respiratory syncytial virus (RSV) infection is made and the infant is admitted to the pediatric unit. What should be included in the nursing plan of care?
Maintain standard and contact precautions.
The mother of a 6-week-old infant asks the nurse at the pediatric clinic why, with the exception of hepatitis B, her baby's immunizations will not be started until the infant is 2 months old. How should the nurse respond?
Maternal antibodies interfere with younger infants' antibody production.
A 5-month-old infant is brought to the pediatric clinic because of exposure to an adolescent sibling with measles. The infant's mother asks the nurse whether her baby can be vaccinated against measles at this age. What should the nurse consider before replying?
Maternal diseases and immunizations
A newborn's immunization program is started. While discussing the immunization schedule for the first 6 months with the parents, the nurse informs them that infants usually are not immunized against:
Measles
The parents of a newborn discuss their infant's need for immunizations with the nurse. Which vaccine will not be administered until the child is at least 12 months of age?
Measles
A nurse confirms that a 9-month-old infant's immunization schedule is up to date. Which immunization will the infant receive at 15 months of age?
Measles, mumps, and rubella (MMR)
A nurse who is caring for a 2-day-old neonate suspects that the infant has cystic fibrosis. What early sign of this disorder did the nurse identify?
Meconium ileus
A 4-month-old infant is brought to the emergency department after 2 days of diarrhea. The infant is listless and has sunken eyeballs, a depressed anterior fontanel, and poor tissue turgor. The infant's breathing is deep, rapid, and unlabored. The mother states that the infant has had liquid stools and no obvious urine output. What problem does the nurse conclude that the infant is experiencing?
Metabolic acidosis
The mother of a 3-month-old infant asks the nurse in the well-baby clinic what toys to give her child. What is the nurse's response? (Select all that apply.)
Metallic mirror Colorful mobile
An 8-month-old infant undergoes surgical correction for hypospadias. What is a priority nursing intervention during the postoperative period?
Minimizing pain with adequate analgesia
What is the priority nursing intervention for a 6-month-old infant with bronchiolitis?
Monitoring skin color, anterior fontanel, and vital signs
What is the priority of nursing care for an infant with a newly applied spica cast?
Monitoring the child's peripheral circulation
A severely dehydrated infant admitted to the pediatric unit is too lethargic to receive oral rehydration therapy, and an intravenous infusion is started. What is the nurse's primary responsibility?
Monitoring the prescribed rate of flow
A nurse is teaching the parents of an infant with a cleft lip and palate how to prevent infection. What information should the nurse include about why the infant is predisposed to infection?
Mouth breathing dries the oropharyngeal mucous membranes.
A nurse plans to discuss childhood nutrition with a group of parents whose children have Down syndrome in an attempt to minimize a common nutritional problem. What problem should be addressed?
Obesity
After several episodes of intermittent abdominal pain and vomiting, a 5-month-old infant is admitted to the pediatric unit. A diagnosis of intussusception is made. What is the priority nursing intervention that will help confirm the diagnosis?
Observing characteristics of stools
A 4-month-old infant had a spica cast applied. What should the nurse include in the discharge instructions to the parents?
Obtain a specially designed car seat.
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?
Obtaining daily weights
A 4-month-old infant is on nothing-by-mouth status in preparation for surgery. What should the nurse do when the infant starts crying?
Offer a pacifier
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 psychosocial theory of development, the nurse determines that the infant is in the:
Oral-sensory stage
A nurse in the pediatric clinic observes an 11-month-old boy who is sitting on his mother's lap crying and tugging at his right ear. What probable problem does this behavior indicate?
Otitis media
Abdominal surgery is planned for a 2-month-old infant. Which item should the nurse provide for the infant on the day of surgery?
Pacifier to suck
An infant is admitted to the hospital with gastroenteritis. The infant vomits shortly after admission. Under standard precautions, what protective equipment should the nurse wear when cleaning the infant after the vomiting episode?
Pair of gloves
A nurse in the pediatric clinic is caring for an 11-month-old infant with iron-deficiency anemia. The infant's hemoglobin is 8 g/dL. What does the nurse expect to observe when evaluating the infant?
Pallor
A nurse is discussing the care of an infant with colic. What should the nurse explain to the parents is the cause of colicky behavior?
Paroxysmal abdominal pain
During a parenting class a nurse is discussing infant/toddler nutrition and ways to reduce the risk of food allergies. What food item should the nurse recommend that the parents avoid until their children are 3 years old?
Peanut butter
What does a nurse recognize as the most serious complication of meningitis in young children?
Peripheral circulatory collapse
An infant has noncommunicating hydrocephalus, and a ventriculoperitoneal shunt is inserted. What should the nurse do when caring for the infant during the initial postoperative period?
Place the infant flat with the head on the unaffected side
What is the nurse's priority intervention when preparing for admission of a child with acute laryngotracheobronchitis?
Placing a tracheotomy set at the bedside
A complete blood count is ordered for a 5-month-old infant with Tetralogy of Fallot. What does the nurse expect to see when reviewing the laboratory results?
Polycythemia
On a visit to the well-baby clinic the parents are upset because their 9-month-old infant has severe diaper rash; one parent wants to know how to treat it and prevent it from recurring. What cause of diaper dermatitis should the nurse include when answering the parent's question?
Prolonged contact with an irritant
A 6-week-old infant has just been found to have gastroesophageal reflux. What teaching is most important to discuss with the parents at this time?
Providing formula thickened with cereal
What intervention is included in the nursing care plan for a 4-month-old infant with tetralogy of Fallot and heart failure?
Providing small, frequent feedings.
A nurse is caring for an infant with exstrophy of the bladder. What other defect associated with this condition does the nurse expect?
Pubic bone malformation
A child with β-thalassemia is receiving therapy that includes multiple blood transfusions. This child is at increased risk for which complication?
Pulmonary edema
A nurse is caring for an infant with talipes equinovarus (clubfoot) who has had a corrective boot cast applied. Which peripheral vascular observation cannot be performed while the cast is in place?
Pulse
A nurse is discussing the diet of an 8-month-old infant with the parents. Which foods can an infant of this age on a regular diet safely be fed? (Select all that apply.)
Pureed pears Pureed carrots Mashed sweet potatoes
During a vaccination drive at a well-child clinic, a nurse notes that a recently hired nurse is not wearing gloves while caring for an infant. What should the nurse advise the newly hired nurse to do?
Put on gloves because standard precautions are required
A nurse sees another health team member cover an infant with a blanket to prevent heat loss. What heat loss mechanism is being minimized by this action?
Radiation
What procedure should a nurse use when elevating the head of an infant in a spica cast?
Raising the entire mattress at the head of the crib
The factor that is most significant for the nurse working with the family of an infant born with a genetic disorder is their:
Readiness to talk about problems their infant may have in the future
A nurse is caring for a 3-month-old infant who was admitted to the pediatric unit with severe dehydration caused by diarrhea. After fluid and electrolyte balance is restored, Lactobacillus granules (Lactinex) are prescribed. The nurse expects this medication to:
Recolonize flora in the intestinal tract
A 3-month-old infant with chronic constipation has a tentative diagnosis of Hirschsprung disease. What definitive diagnostic test does the nurse expect to prepare the infant for?
Rectal biopsy
After surgery for repair of a myelomeningocele, the nurse places the infant in a side-lying position with the head slightly elevated. The main reason the nurse places the infant in this position after this particular surgery is that it:
Reduces intracranial pressure
On the day after surgery for insertion of a ventriculoperitoneal shunt to treat hydrocephalus, an infant's temperature increases to 103.0° F (39.4° C). The nurse immediately notifies the practitioner. What is the next nursing action?
Removing excess clothing from the infant
A child is admitted to the hospital with pneumonia. What is the priority need that must be included in the nursing care for this child?
Rest
An infant is admitted to the pediatric unit with bronchiolitis caused by the respiratory syncytial virus (RSV). What medication does the nurse anticipate that the practitioner will prescribe?
Ribavirin
A nurse determines that no further health teaching is needed for the parents of a 6-month-old infant when they state that they will introduce new foods in the recommended order. List the order in which these new foods should be introduced.
Rice cereal Oatmeal cereal Mashed bananas Pureed beef Soft-boiled eggs
Which cardiac defects are associated with tetralogy of Fallot?
Right ventricular hypertrophy, ventricular septal defect, pulmonic stenosis, and overriding aorta
The parents of an infant with tetralogy of Fallot ask the nurse to explain what is wrong with their baby's heart. Before explaining the problem in a way that they will understand, the nurse remembers that tetralogy of Fallot includes:
Right ventricular hypertrophy, ventricular septal defect, pulmonic stenosis, and overriding of the aorta
A nurse is feeding an infant who recently underwent surgical repair of a cleft lip. What does the nurse plan to do for the infant just after each feeding?
Rinse the suture line
A nurse is reviewing the immunization schedule of an 5-month-old infant. What immunizations does the nurse expect the infant to have already received?
Rotavirus, DTaP, Haemophilus influenzae, polio, pneumococcal
A nurse is caring for an infant after a cleft lip repair. Which item should the nurse use to feed the infant for several days after the surgery?
Rubber-tipped syringe
Which item should a nurse use to feed an infant born with a unilateral cleft lip and palate?
Rubber-tipped syringe
A postpartum nurse is reviewing principles related to automobile infant restraint systems with the parents of a newborn who is to be discharged in the morning. What information should be included in the teaching session? (Select all that apply.)
Secure the infant seat so that it faces the rear. Follow the manufacturer's directions to secure the infant seat in the back seat. Be sure to follow weight guidelines set forth in the manufacturer's instructions.
An infant is receiving intermittent nasogastric tube feedings. In what position should the nurse place the infant?
Semi-Fowler
A newborn has just been admitted to the pediatric surgical unit from the birth hospital with a diagnosis of tracheoesophageal fistula. In what position should this child be maintained?
Semi-Fowler, to reduce the risk of chemical pneumonia
An infant who weighed 7.5 lb at birth now weighs 15 lb at 1 year. The nurse concludes that this infant's weight gain:
Signifies an inadequate weight gain
A mother arrives in the emergency department with her severely dehydrated infant. After being treated aggressively, the infant is rehydrated and ready to be discharged. What is the priority concern that should be included in the discharge teaching plan for the mother?
Signs of dehydration in infants
While performing care of an infant with hypertrophic pyloric stenosis (HPS) the nurse observes visible peristaltic waves. What other sign of HPS should the nurse expect?
Small mass in the right upper quadrant
Children's patterns of play change as they grow from infancy through school-age. Rank the order of appearance of each type of play, starting with infant play.
Solitary Parallel Associative Cooperative
An infant who has undergone surgery for hypertrophic pyloric stenosis (HPS) is being bottle fed by the mother. What should the nurse teach the mother about feedings to decrease the chance of the infant vomiting?
Start with small, frequent feedings.
An infant is born with exstrophy of the bladder. What instruction by the health care provider does the nurse expect to protect the exposed bladder until surgery is performed?
Sterile nonadherent dressings
The nurse is teaching a parent group about the reason to adhere to the immunization schedule. What complication of mumps is important for adolescents to avoid?
Sterility
The mother of a 5-month-old infant asks the nurse in the well-baby clinic to tell her the order in which new foods should be introduced. The nurse responds that once infant cereals have been introduced, the foods that are best for an infant of this age include:
Strained vegetables
A 5-month-old child undergoes heart surgery to repair the defects associated with tetralogy of Fallot. Prevention of what behavior is a priority for the nurse after the surgery?
Straining at stool
A nurse is teaching a class about behavioral expectations of infants and children to a group of parents. The nurse includes those behaviors expected of 8-month-old infants. (Select all that apply.)
Stranger anxiety Playing peek-a-boo Standing by holding on to furniture
A 4-month-old infant is admitted to the pediatric unit with severe tachypnea, flaring of the nares, wheezing, and irritability. The parents are told that the child has bronchiolitis and needs to be hospitalized for observation and treatment. While evaluating the infant, the nurse determines that the infant is in respiratory failure. What clinical finding supports the nurse's conclusion?
Sudden absence of breath sounds
A 2-month-old infant is admitted to the pediatric unit with gastroenteritis and dehydration. Which finding should the nurse anticipate?
Tachycardia
A 5-month-old infant is admitted with a diagnosis of respiratory syncytial virus (RSV) infection. The infant's condition suddenly deteriorates and a dose of epinephrine is prescribed to relieve bronchospasm. For what side effect of the medication should the nurse assess the infant?
Tachycardia
A 5-month-old infant is admitted with a diagnosis of respiratory syncytial virus (RSV) infection. The infant's condition suddenly deteriorates and a dose of epinephrine is prescribed to relieve bronchospasm. For what side effect of the medication should the nurse evaluate the infant?
Tachycardia
A 9-month-old infant is admitted to the pediatric unit with a possible head injury. Twelve hours later the nurse determines that the previous blood pressures were taken using a neonate-size cuff. The nurse documents the size of the cuff that was used for previous measurements. What is the best action for the nurse to take?
Taking the next measurement with both a neonate- and a child-size cuff
A nurse teaches a mother about appropriate play for an 8-month-old infant. Which of the mother's suggestions indicate that the teaching has been understood? (Select all that apply.)
Textured book Stuffed animal Hanging mobile
One minute after birth a neonate's heart rate is 106 beats/min; acrycyanosis and muscle tone with flexion are observed; flicking the sole triggers crying; and the cry is strong. What is the neonate's Apgar score? Record your answer using a whole number. __________
The Apgar score is calculated from scores in five areas: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each area is given a score of 0, 1, or 2. Pulse over 100 = 2 points; good cry = 2 points; good muscle tone = 2 points; excellent reflex irritability (stimulus precipitates a cry) = 2 points; bluish extremities (acrocyanosis) = 1 point. 9 points
An infant is undergoing parenteral therapy. The health care provider has instructed that 400 mL of D5W 0.45% sodium chloride be infused over 8 hours. At how many milliliters per hour should the nurse maintain the hourly rate? Record your answer using a whole number. __________ mL
The correct rate is 50 mL/hr. Divide the total volume to be infused (400 mL) by the number of hours it is to be infused in (8): 400 ÷ 8 = 50 mL.
After receiving levothyroxine (Synthroid) for 3 months for congenital hypothyroidism an infant is brought to the pediatric clinic for a checkup. What does the mother tell the nurse about her baby that indicates that the drug is effective?
The infant's stools are soft.
A nurse suspects that a 7-month-old infant who is brought to the well-baby clinic for the first time has a hearing deficit. What behavior leads the nurse to come to this conclusion?
The mother says the infant stopped making verbal sounds about a month ago.
The nurse anticipates that a child born with a missing chromosome is most likely to have:
Turner syndrome
A 7-month-old girl is to be catheterized so a sterile urine specimen may be obtained. One of the infant's parents expresses fear that this procedure may traumatize the baby psychologically. How should the nurse provide reassurance?
The procedure is uncomfortable, but there should not be a damaging long-term effect.
The parents of an infant who just underwent insertion of a ventriculoperitoneal shunt for hydrocephalus are concerned about the prognosis. What information should the nurse give the parents?
The shunt may need to be replaced as the child grows older.
A 1-month-old infant is being treated with sequential casts for bilateral clubfoot (talipes eqinovarus); new casts have just been applied. The goal at this time is ensuring that circulation to the feet remains sufficient. How will the nurse determine that the goal is being met?
The toes, when compressed, exhibit a quick return of circulation.
The mother of a boy with recently diagnosed hemophilia is pregnant with her second child. She asks the nurse what the chances are that her baby will also have hemophilia. How should the nurse respond?
There is a 25% chance that the baby will be affected.
A nurse is planning to evaluate the vomitus of an infant with pyloric stenosis. Why does the nurse anticipate that the vomitus will be white rather than bile-stained?
There is an obstruction above the opening of the common bile duct.
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?
This autosomal recessive disorder was inherited from parents who are carriers.
A 6-week-old infant grasps a rattle placed in the hand. The mother is impressed with this skill. What should the nurse teach the mother about this behavior?
This is the palmar grasp reflex and is expected at this age.
An infant has been admitted for dehydration as a result of acute gastroenteritis and vomiting, and the nurse administers lactated Ringer's solution intravenously. The nurse concludes that the treatment has been effective after noting:
Three wet diapers in 24 hours
A nurse is reviewing the laboratory report of an infant with tetralogy of Fallot that indicates an increased red blood cell (RBC) count. What does the nurse identify as the cause of the polycythemia?
Tissue oxygen needs
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, the nurse determines that the infant is in the process of achieving the task of:
Trust
If a 5½-month-old infant's immunizations are on schedule, which immunizations does the nurse expect the infant to have had already?
Two doses of diphtheria, tetanus, and pertussis vaccine
A nurse is concerned about helping the parents of an infant with cerebral palsy set long-term goals for the family. These goals should be set with the understanding that:
Unknown extent of the disability requires continual adjustments
An infant child with juvenile idiopathic arthritis is seen in the clinic. Ibuprofen 90 mg by mouth every 6 hours is prescribed. Ibuprofen is available in a solution of 100 mg/2.5 mL. How many milliliters should the nurse instruct the parents to give with each dose? Record your answer rounding to two decimal places. __________ mL
Use ratio and proportion to calculate the dose. Desire 90 mg x mL ----------------- = ------ Have 100 mg 2.5 mL 100x = 225 x = 225 ÷ 100 x = 2.25 mL
An infant is born with a cleft lip. What nursing intervention is unique to infants with cleft lip?
Using modified techniques for feeding
A 2-month-old infant is to receive the second hepatitis B vaccination. What muscle should the nurse select for the injection?
Vastus lateralis
A mother introducing cereal into her infant's diet asks the nurse about the sequence she should follow when introducing new foods. What order should the nurse suggest?
Vegetables and fruits should be introduced before meats because of the generous amounts of vitamins and minerals they supply; the introduction of meats is delayed until after 6 months of age. Table foods are introduced after the infant can chew or bite (6 to 7 months). This is not the appropriate first choice because meats are more likely to be allergenic. Fruits may be introduced first, but table foods should be introduced last, after the other foods are tolerated.
The mother of a 5-month-old infant tells the nurse that she has started to feed her baby fortified cereal mixed with formula. She asks in which order she should introduce new foods. What foods should be selected first?
Vegetables and noncitrus fruits
A 1-week-old infant has been in the pediatric unit for 18 hours after placement of a spica cast. The nurse obtains a respiratory rate slower than 24 breaths/min; no other changes are noted. Because the infant is apparently well, the nurse does not report or document the slow respiratory rate. Several hours later the infant experiences severe respiratory distress and emergency care is necessary. What should be considered if legal action is taken?
Vital signs that are outside the expected parameters are significant and should be documented.
A nurse teaches the parents of a 1-year-old infant that the primary developmental milestone to be accomplished between 12 and 15 months of age is the ability to:
Walk erect
An infant with diarrhea requires contact precautions. What is the most effective nursing action to control the spread of this infant's pathogens?
Washing hands before and after contact with the infant
A 6-week-old infant is brought to the clinic by the parents. The mother states that the baby has been vomiting with increasing frequency and force after feeding. Hypertrophic pyloric stenosis (HPS) is diagnosed by the practitioner. What clinical findings of HPS does the nurse expect to identify? (Select all that apply.)
White vomitus Peristaltic waves Insatiable hunger
A nurse is planning to obtain a blood specimen from a 4-week-old high-risk infant in the neonatal intensive care unit to test for hypoglycemia. At which point, on the figure of the bottom of the infant's foot, should the automatic lancet device be placed?
c
