Infant
The parents of a 3-week-old healthy newborn ask the nurse why their child is intermittently cross-eyed. What is the nurse's best response? "An eye patch may be necessary to correct your child's vision." "Your child will likely need an ophthalmology consult." "It is normal to have eye-crossing in the newborn period." "Surgery may be necessary to correct your child's vision."
"An eye patch may be necessary to correct your child's vision."
The nurse obtains the nursing history from the parent of an infant with suspected intussusception. Which question would be most helpful for the nurse to ask? "What do the stools look like?" "When was the last time your child urinated?" "Is your child eating normally?" "Has your child had any episodes of vomiting?"
"What do the stools look like?"
A parent brings an infant to the health clinic for a well-baby checkup. During the assessment, the nurse measures the head circumference of the child and notes that there has been a rapid increase in size. What action should the nurse take next? Document that growth is occurring quickly. Obtain an order to administer a diuretic. Assess for signs of increased intracranial pressure. Teach the parent how to protect the child's head.
Assess for signs of increased intracranial pressure.
A nurse is conducting an examination of a 6-month-old infant. The nurse documents what finding as indicative of normal development? Babinski startle Moro dance
Babinski
When assessing the chest of a 4-month-old infant, the nurse identifies the ratio of the anteroposterior-to-lateral diameter as 1:1. What action should the nurse take next? No action is needed; this is a normal finding. Inform the physician of the finding and obtain an order for a chest X-ray. Instruct the parents to bring the infant back in 1 month for reevaluation. Check the infant for signs of respiratory distress.
No action is needed; this is a normal finding.
A nurse is performing a neurologic assessment on an infant. When assessing for function of cranial nerve X (vagus), which technique is most appropriate to use? Press a tongue blade on the posterior surface of the tongue. Observe for spontaneous eye movement. Lightly brush a cotton swab across the child's cheek. Assess for smiling or forceful eye closing with crying.
Press a tongue blade on the posterior surface of the tongue.
The nurse is assessing the development of a 7-month-old. The child should be able to perform which skill? Play pat-a-cake. Sit without support. Say two words. Wave bye-bye.
Sit without support.
Erik Erikson's Five Stages of Psychosocial Development in order Identity versus role confusion Industry versus inferiority Trust versus mistrust Initiative versus guilt Autonomy versus shame and doubt
Trust versus mistrust Autonomy versus shame and doubt Initiative versus guilt Industry versus inferiority Identity versus role confusion
The caregiver of a 2-month-old client calls stating that the client is "fussy and has a runny nose." The caregiver states that the client has been sleeping poorly at night and is not eating as well. Which of the following interventions will the nurse teach the caregiver? Give the client an over-the-counter cough-and-cold medicine. Have the caregiver make an appointment with the healthcare provider for antibiotics. Encourage the caregiver to administer aspirin as needed for fever. Use a bulb syringe to suction out the nasal passages.
Use a bulb syringe to suction out the nasal passages.
A client brings her 6-month-old infant in for a well-baby visit. During the exam, the nurse is unable to elicit the Moro reflex. Which is the appropriate action by the nurse? explaining to the client that this reflex disappears around 3-4 months contacting the physician with the finding waiting 5 minutes then attempting to elicit the reflex again explaining that this reflex disappears around 6-8 weeks
explaining to the client that this reflex disappears around 3-4 months
A 6-month-old infant is assessed to have 4% volume depletion related to a gastrointestinal illness. What intervention would the nurse recommend to the parents based on the infant's condition? oral electrolyte replacement solutions, breast milk, or lactose-free formula IV fluid replacement therapy and nothing per oral (NPO) for next 48 hours clear fluids, such as fruit juices, carbonated soft drinks, and gelatin BRAT diet (bananas, rice, apples, and toast or tea) until stools are firm
oral electrolyte replacement solutions, breast milk, or lactose-free formula
Which of the following actions is correct when the student nurse assesses the fontanels of a 6-week-old infant? palpating the fontanels gently while the infant sits on the parent's lap probing the fontanels firmly while the infant is prone on the table observing for the bulge of the fontanels while the infant cries noting the shape of the fontanels while the infant lies flat
palpating the fontanels gently while the infant sits on the parent's lap
When preparing a 20-month-old for removal of a foreign body in the nasal passage by the health care provider, the nurse should use which method of restraint? jacket restraint elbow restraint use of father to hold papoose board
papoose board
Which finding indicates that the infant has adequately evacuated the barium after undergoing a barium enema? absence of fecal mass in the lower abdomen stools that progress from clay-colored to brown bowel sounds of 30 per minute stool guaiac that is negative
stools that progress from clay-colored to brown
For the past 6 days, a 7-month-old infant has been receiving amoxicillin trihydrate to treat an ear infection. Now the parents report redness in the diaper area and small, red patches on the infant's inner thighs and buttocks. After diagnosing Candida albicans, the physician orders topical nystatin to be applied to the perineum four times daily. The nurse should focus her assessment on: the infant's heart and respiratory rate. the infant's fontanels. the inside of the infant's mouth. the infant's height and weight.
the inside of the infant's mouth.
The nurse is inserting a nasogastric tube in an infant to administer feedings. In the figure below, indicate the location for the correct placement of the distal end of the tube.
stomach
A nurse is teaching a new parent how to prevent burns in the home. Which statement by the parent indicates more teaching is required? "I will set my hot water heater to 120°F (49°C)." "I will not hold my infant while drinking coffee." "I will heat my infant's formula in the microwave." "I will keep loose appliance cords tied up on the counter."
"I will heat my infant's formula in the microwave."
A community nurse is working with the family of an infant and teaching the parents about preventative health practices. What method of primary prevention the nurse to include in the teaching? child-proofing the home testing suck reflexes testing grasp reflexes performing screening tests
child-proofing the home
The parent of an infant with a cleft lip asks when the repair will be scheduled. What is the nurse's best response? at birth during the first 6 months of life between the ages of 6 months and 1 year after 1 year of age
during the first 6 months of life
A first-time mother is concerned that her 6-month-old infant is not gaining enough weight. What should the nurse tell the mother? "Birth weight doubles by 6 months of age." "Using a body mass index (BMI) for age growth chart is the best way to assess proper weight gain." "The baby will eat what he needs." "You need to make sure the baby finishes each bottle."
"Birth weight doubles by 6 months of age."
A parent asks, "How should I bathe my baby now that they have had surgery for an inguinal hernia?" Which instruction should the nurse give the parent? "Clean only their face and diaper area for the next 2 weeks." "Use sterile sponges to cleanse the inguinal incision until healed." "Give them a sponge bath daily for 1 week." "Let them take a full tub bath daily."
"Give them a sponge bath daily for 1 week."
A nurse is teaching the parent of a 5-month-old infant diagnosed with bronchiolitis. Which statement by the mother indicates that teaching has been effective? "I hope my baby will come home from the hospital." "I know that this disease is serious and can lead to asthma." "My baby needs to be cured this time so it won't happen again." "My baby has been sick. A machine will help him breathe."
"I know that this disease is serious and can lead to asthma."
A bottle-fed infant, age 3 months, is brought to the pediatrician's office for a well-child visit. During the previous visit, the nurse taught the parent about infant nutritional needs. Which statement by the parent during the current visit indicates effective teaching? "I started the baby on cereals and fruits because the baby wasn't sleeping through the night." "I started putting cereal in the bottle with formula because the baby kept spitting it out." "I'm giving the baby iron-fortified formula and a fluoride supplement because our water isn't fluoridated." "I'm giving the baby skim milk because the baby was getting so chubby."
"I'm giving the baby iron-fortified formula and a fluoride supplement because our water isn't fluoridated."
Metabolic screening of an infant revealed a high phenylketonuria (PKU) level. Which statement(s) by the infant's parent indicates an understanding of the disease and its management? Select all that apply. "My baby cannot have milk-based formulas." "My baby will grow out of this by the age of 2 years." "This is a hereditary disease, so any future children will have it, too." "My baby will eventually become intellectually disabled because of this disease." "We have to follow a strict low-phenylalanine diet." "A dietitian can help me plan a diet that keeps a safe phenylalanine level but lets my baby grow."
"My baby cannot have milk-based formulas." "We have to follow a strict low-phenylalanine diet." "A dietitian can help me plan a diet that keeps a safe phenylalanine level but lets my baby grow."
A 7-month-old infant is admitted to the hospital with a tentative diagnosis of Hirschsprung disease. When the nurse is obtaining the infant's initial health history from the parents, which statement made by the parent would be most consistent with the diagnosis of Hirschsprung disease? "They get constipated often." "Sometimes they get a cold." "They spit up occasionally." "Their rectal temperature is 99.4°F (37.4°C)."
"They get constipated often."
After the nurse instructs the parents of a 5-month-old infant about the purpose of the Denver Developmental Screening Test (DDST), which statement by the parents about what the test measures would indicate that the teaching was effective? "This test measures a child's IQ." "This test measures a child's emotional development." "This test measures a child's social and physical abilities." "This test measures a child's potential for future development."
"This test measures a child's social and physical abilities."
An 8-month-old infant is admitted with a febrile seizure. The infant weighs 17 lb (7.7 kg). The physician orders ceftriaxone, 270 mg I.M. every 12 hours. (The safe dosage range is 50 to 75 mg/kg daily.) The pharmacy sends a vial containing 500 mg, to which the nurse adds 2 ml of preservative-free normal saline solution. The nurse should administer how many milliliters? None, because this is not a safe dosage 0.08 ml 1.08 ml 1.8 ml
1.08 ml
A nurse is caring for an infant who weighs 8 kg and is ordered to receive ampicillin 25 mg/kg intravenously every 6 hours. How many milligrams would a nurse administer per dose? Record the answer as a whole number.
200 mg/dose
Before surgery, a neonate is to receive an IM injection of an antibiotic. Which gauge and size of needle should the nurse select? 19G, 1½″ (3.8-cm) needle 20G, 1″ (2.5-cm) needle 23G, 2″ (5-cm) needle 25G, ⅝″ (1.6-cm) needle
25G, ⅝″ (1.6-cm) needle
The parent says that the infant's health care provider recommends certain foods, but the 7-month-old infant refuses to eat them after breastfeeding. How should the nurse suggest that the parent alter the feeding plan? Offer dessert followed by some vegetables and meat. Offer breast milk as long as the infant refuses to eat solid foods. Mix pureed food with some breast milk in a bottle with a large-holed nipple. Allow the infant to nurse for a few minutes and then offering solid foods.
Allow the infant to nurse for a few minutes and then offering solid foods.
When performing a physical examination on a neonate, the nurse notes low-set ears. What action should the nurse perform next? Call the pediatrician for an immediate evaluation of the infant. Note the findings in the medical record. Assess the neonate to determine if other apparent abnormalities are present. Order an ultrasound of the head to determine if the brain is normal.
Assess the neonate to determine if other apparent abnormalities are present.
The father of a neonate observes that the neonate's big toe dorsiflexes and the other toes fan when the nurse gently strokes the sole of the foot. How should the nurse should interpret this finding? stepping reflex plantar grasp reflex Galant reflex Babinski's sign
Babinski's sign
When assessing a 2-month-old infant, the nurse feels a "click" when abducting the infant's left hip. What should the nurse do next? Document the finding as normal for a 2-month-old. Check the lengths of the femurs to determine if they are equal. Instruct the mother to keep the leg in an adducted position. Reschedule the child for a follow-up assessment in 3 weeks.
Check the lengths of the femurs to determine if they are equal.
A nurse observes a hospitalized 10-month-old infant chewing on the security alarm attached to his identification bracelet. What intervention is most appropriate for the nurse to perform? Remove the security device because it's a choking hazard. Cover the device with gauze wrap so that it isn't visible. Distract the infant with a more appropriate toy. Instruct the infant's parents regarding the safety hazard.
Distract the infant with a more appropriate toy.
During the nurse's assessment, the newborn wakes and is in a quiet-alert state. The nurse counts the apical pulse to be 157 beats per minute. Which is the most appropriate nursing action? Call the pediatrician because this finding is dangerously high. Document this finding as on the low end of the normal range and plan to reassess. Document this finding as on the high end of the normal range and plan to reassess. Notify the charge nurse because this finding is on the low end of the normal range given the newborn's quiet-alert state.
Document this finding as on the high end of the normal range and plan to reassess.
Three weeks after an infant receives a spica cast, the parent calls the nurse because the infant's toes are swollen and cool to the touch. What should the nurse instruct the parent to do? Place the child's legs in a lowered position. Have the child fitted for a larger cast. Put more cotton wadding to line the casting. Inspect the area for an infection.
Have the child fitted for a larger cast.
Twenty-four hours after birth, a neonate has not passed meconium. The infant's abdomen is firm with hypoactive bowel sounds. The nurse anticipates the healthcare provider will diagnose which condition? Hirschsprung's disease celiac disease intussusception abdominal wall defect
Hirschsprung's disease
The mother of an infant with a congenital heart defect involving decreased pulmonary blood flow tells the nurse that her child has not been gaining weight even with an increased-calorie formula. The mother states that the infant starts out with a good suck but tires and quits after 2 ounces (60 mL). The infant is receiving oxygen through a nasal cannula as necessary and is on digoxin therapy. Which action should the nurse suggest to the mother? Cut a large hole in the nipple. Feed the infant every 2 hours. Have the infant tested for digoxin toxicity. Increase the oxygen for feedings.
Increase the oxygen for feedings.
An intravenous (IV) infusion is to be administered through a scalp vein on an infant's head. What should the nurse tell the parents to prepare them for the procedure? It may be necessary to remove a small amount of hair from the infant's scalp. A sedative will be given to help keep the infant quiet. Visiting the infant will be delayed until the infusion has been completed. Holding the infant will be contraindicated while the infusion is being administered.
It may be necessary to remove a small amount of hair from the infant's scalp.
The nurse is caring for an 8-month-old infant who was initially feeding well but is now failing to suck and swallow. Which of the following assessments should be a priority for the nurse based on this information? Assess bowel sounds. Palpate for an enlarged liver. Perform a neurologic assessment. Review recent urinary output.
Perform a neurologic assessment.
Which nursing intervention is most important postoperatively for an infant who has received a ventriculoperitoneal shunt? Monitor head circumference. Initiate oral feedings. Allow the infant to rest undisturbed. Provide age-appropriate diversionary activities.
Monitor head circumference.
The nurse is caring for a 9-month-old with Reye syndrome. Which nursing intervention should be included when assisting with the plan of care? Check the skin for signs of breakdown every shift. Perform range-of-motion (ROM) exercises every 4 hours. Monitor the child's intake and output. Place the child in protective isolation.
Monitor the child's intake and output.
The nurse is giving care to an infant with a brain tumor. The nurse observes the infant arches their back (see figure). What action should the nurse take first? Notify the health care provider (HCP). Stroke the back to release the arching. Pad the side rails of the crib. Place the child prone.
Notify the health care provider (HCP).
While gently abducting the hips during a newborn assessment, the nurse hears a "click" as the femoral head slips into the acetabulum. The nurse interprets this as positive for which physical finding? Barlow test Galeazzi sign Ortolani sign Trendelenburg sign
Ortolani sign
The nurse is performing an assessment in the nursery on an infant with a developmental hip dysplasia. Which findings should the nurse anticipate? symmetrical thigh and gluteal folds Ortolani's sign increased hip abduction femoral lengthening
Ortolani's sign
The nurse develops the teaching plan for the parents of a 12-month-old infant with hypospadias and chordee repair. What information is most important to include? Assist the child to become familiar with their dressings so they will leave them alone. Encourage the child to ambulate as soon as possible by using a favorite push toy. Force fluids to at least 2500 mL a day by offering their favorite juices. Prevent the child from disrupting the catheters by using soft restraints if needed.
Prevent the child from disrupting the catheters by using soft restraints if needed.
The parents of a 3-month-old infant have been told that their infant has died of sudden unexplained infant death syndrome (SUIDS). Which intervention is most important to include in the plan of care to assist the parents with their grieving process? Reassure the parents that the infant's death was not their fault. Provide an opportunity for the parents to see the infant. Ask the parents if they would like to call their religious advisor. Give the parents a package containing the infant's clothing.
Provide an opportunity for the parents to see the infant.
An older infant who has been injured in an automobile accident is to wear a splint on the injured leg. The parent reports that the infant has become mobile even while wearing the splint. What should the nurse advise the parent to do? Notify the health care provider (HCP) immediately to adjust the treatment plan. Confine the infant to one room in the apartment. Keep the infant in the splint at night, removing it during the day. Remove any unsafe items from the area in which the infant is mobile.
Remove any unsafe items from the area in which the infant is mobile.
A diagnosis of hemophilia A is confirmed in an infant. Which instruction should the nurse provide the parents as the infant becomes more mobile and starts to crawl? Administer one-half of a children's aspirin for a temperature higher than 101° F (38.3° C). Sew thick padding into the elbows and knees of the child's clothing. Check the color of the child's urine every day. Expect the eruption of the primary teeth to produce moderate to severe bleeding.
Sew thick padding into the elbows and knees of the child's clothing.
A parent tells the nurse that their 8-month-old infant is anxious. Which suggestion by the nurse is most appropriate to help the parent lessen anxiety in the infant? Limit holding the infant to feeding times. Talk quietly to the infant while he is awake. Play music in his room for most of the day and night. Have a close friend keep the infant for a few days.
Talk quietly to the infant while he is awake.
A 10-month-old child looks for objects that have been removed from their view. How does the nurse explain the finding to the parents? The child is showing typical neuromuscular development. The child's curiosity has increased. The child understands objects are there even though the child cannot see them. The child's long-term memory has increased.
The child understands objects are there even though the child cannot see them.
The nurse is caring for an infant who exhibits the above characteristics. When planning care, which would be the best long term client goal? The client will feed himself/herself independently. The client will reach his/her optimal level of functioning. The client will care for himself/herself without supervision. The client will express his/her thoughts and feelings.
The client will reach his/her optimal level of functioning.
The nurse teaches the parents of an infant who has had surgery to correct imperforate anus how to position the infant to prevent tension on the perineum. The nurse determines more teaching is needed when the parents put the infant in which position? abdomen, with legs pulled up under the body back, with legs suspended at a 90-degree angle left side, with hips elevated right side, with hips elevated
abdomen, with legs pulled up under the body
Eight hours ago, an infant with Hirschsprung's disease had surgery to create a colostomy. Which finding should alert the nurse to notify the health care provider (HCP) immediately? a 3-cm increase in abdominal circumference periods of occasional fussiness absence of bowel sounds since surgery bright red stoma
a 3-cm increase in abdominal circumference
The nurse plans to do a home visit with the parents of an infant who died of sudden unexplained infant death syndrome (SUIDS) at home. When should the nurse visit the parents? a few days after the funeral 2 weeks after the funeral as soon as the parents are ready to talk as soon after the infant's death as possible
as soon after the infant's death as possible
The nurse is evaluating an infant for auditory ability. What is the expected response in an infant with normal hearing? blinking and stopping body movements when sound is introduced evidence of shy and withdrawn behaviors saying "da-da" by age 5 months absence of squealing by age 4 months
blinking and stopping body movements when sound is introduced
When performing cardiopulmonary resuscitation on a 7-month-old infant, which location would the nurse use to evaluate the presence of a pulse? carotid artery femoral artery brachial artery radial artery
brachial artery
An infant has just had surgery to repair a cleft lip. Which nursing intervention is most important during the immediate postoperative period? cleaning the suture line carefully with a sterile solution after every feeding laying the infant on the abdomen to help drain fluids from the mouth allowing the infant to cry to promote lung reexpansion giving the infant a pacifier to suck for comfort
cleaning the suture line carefully with a sterile solution after every feeding
The nurse develops the discharge plan for the parents of an infant who has undergone a myelomeningocele repair. What information is most important for the nurse to include? a list of available hospital services schedule for daily home health care chaplain referral for psychological support daily care required by the infant
daily care required by the infant
A 3-month-old infant is admitted to the hospital to rule out nonaccidental trauma. X-ray findings indicate a fractured right humerus, fractured ribs, and a fractured left scapula. In this situation, a nurse is responsible for: ensuring that the suspected child abuse is reported to local authorities. contacting the infant's next of kin to begin discharge planning. reporting the suspicions to the hospital's chief of pediatric services. contacting the local children's protective service office with an anonymous tip.
ensuring that the suspected child abuse is reported to local authorities.
A 5-month-old infant is brought to the clinic by their parents because the infant "cries too much" and "vomits a lot." The infant's birth weight was 3000 g (6 lb, 10 oz), and their current weight is 3289 g (7 lb, 4 oz), falling below the 5th percentile on a standard growth chart. Which data should the nurse identify as the priority? frequency of regular checkups feeding pattern pattern of weight gain family dynamics
feeding pattern
The nurse determines the parents' compliance with treatment for their infant who has otitis media. Which behavior would indicate that the parents are adhering to the treatment plan? cleaning the child's ear canals with hydrogen peroxide administering continuous, low-dose antibiotic therapy instilling ear drops regularly to prevent cerumen accumulation holding the child upright when feeding with a bottle
holding the child upright when feeding with a bottle
The administration of medications during infancy is often necessary. The nurse needs to be concerned about the metabolism of these drugs. What concern regarding metabolism should the nurse consider when administering medications to an infant? decreased glomerular filtration reduced protein-binding ability increased tubular secretion inefficient liver function
inefficient liver function
A 3-month-old has moderate dehydration. The nurse should assess the client for which sign of moderate dehydration? oliguria bulging eyes sunken posterior fontanelle pale skin color
oliguria
A 4-month-old infant is diagnosed with congenital hypothyroidism and prescribed levothyroxine. When should the nurse teach the parents to administer the medication? with the nighttime formula 30 minutes after meals on an empty stomach regardless of meals
on an empty stomach
An 8-month-old infant is seen in the well-child clinic for a routine checkup. The nurse should expect the infant to be able to do which task(s)? Select all that apply. saying "mama" and "dada" with specific meaning feeding self with a spoon playing peek-a-boo walking independently stacking two blocks transferring an object from hand to hand
playing peek-a-boo transferring an object from hand to hand
The nurse prepares to admit an infant diagnosed with diarrhea to the pediatric unit. Which room should the nurse assign the infant to? single negative pressure room two-bed room with an infant with respiratory disease private room room with other infants younger than age 1 year
private room
The health care team determines that the family of an infant with failure to thrive who is to be discharged will need follow-up care. Which approach would be the most effective method of follow-up? daily phone calls from the hospital nurse enrollment in community parenting classes twice-weekly clinic appointments weekly visits by a community health nurse
weekly visits by a community health nurse
An 8-month-old infant is brought to the emergency department following a fall from a high chair and a possible head injury. The parents are distressed because the infant is crying and irritable. The mother asks if she can try to breastfeed the infant. What is the nurse's best response? "We can provide a bottle of water because clear fluids are best right now." "We can put you in a private area to feed, but we will need to reassess frequently." "Until assessments are complete, we should not give your child anything by mouth." "Yes, we recommend calming the child to reduce any increased pressures in the brain."
"Until assessments are complete, we should not give your child anything by mouth."
After receiving a report, the nurse is making out assignments. Which client would be appropriate to assign to unlicensed assistive personnel? 6-year-old with a femur fracture and a fever 13-year-old adolescent with fluctuating vital signs and a new central line 7-year-old transferred from the cardiac intensive care unit 8-month-old with pneumonia who will be discharged today
8-month-old with pneumonia who will be discharged today
The nurses teaches the parents of an infant how to perform back slaps to dislodge a foreign body. What should the nurse tell the parents to use to deliver the blows? palm of the hand heel of the hand fingertips entire hand
heel of the hand
An infant, age 6 weeks, is brought to the clinic for a well-baby visit. Which position is best for the nurse to assess the fontanel? placed in supine position placed in prone position placed in the left lateral position held in upright position
held in upright position
The parent of an infant with hemophilia tells the nurse that they are planning to do homeschooling when the child reaches school age. The parent does not want their child in school because the teacher will not watch the child as well as the parent would. The parent's comments represent what common parental reaction to a child's chronic illness? overprotection devotion mistrust insecurity
overprotection
The nurse assesses an infant who has had surgery to correct an intussusception and is now at risk for the development of a paralytic ileus postoperatively. Which assessment should be the priority? measurement of urine specific gravity auscultation of bowel sounds inspection of the first stool passed measurement of gastric output
auscultation of bowel sounds
Which nursing activity supports the principles of palliative care for a dying infant and the infant's family? maintaining routines and structure for the infant and the infant's family clustering care activities to provide as much rest as possible for the infant creating a therapeutic, homelike environment for the infant and the infant's family minimizing noise and disruption to decrease stress for the infant
creating a therapeutic, homelike environment for the infant and the infant's family
While examining an 11-month-old child, the nurse notes that the child can stand independently but cannot walk without support. How should the nurse intervene? Recommend the child uses a walker at home. Do nothing because this is a normal finding in a child this age. Initiate a consultation with a developmental specialist. Tell the parent that the child may have a developmental delay.
Do nothing because this is a normal finding in a child this age.
A 1-year-old child is admitted to the hospital with sickle cell crisis. Which intervention does the nurse anticipate will be included in the child's plan of care? parenteral iron therapy exchange transfusion IV fluid therapy fast-acting anticoagulant therapy
IV fluid therapy
The nurse is treating an 8-month-old infant with scabies. What medication would the nurse prepare to administer for this infant? griseofulvin tolnaftate thiabendazole permethrin
permethrin
After gathering all necessary equipment and setting up the supplies, what should be the first step in performing endotracheal (ET) or tracheal suctioning in an infant? Provide extra oxygen by using a ventilator or through manual bagging. Insert a suction catheter to the appropriate measured length. Insert a few drops of sterile saline solution. Put on clean gloves.
Provide extra oxygen by using a ventilator or through manual bagging.
A nurse is caring for an infant who is in critical condition. The nurse notes that the child weighs 11 lb (5 kg) and has had a blood loss of 100 mL. Assessment reveals a decreased urine output, mild tachycardia, and restlessness. Which of the following should be the priority action for the nurse to take? neurologic assessment with the Glasgow Coma Scale application of telemetry monitoring IV administration of lactated Ringer's insertion of a Foley indwelling catheter
IV administration of lactated Ringer's
A 6-month-old infant is brought to the clinic. The mother reports the infant has been lethargic and not eating well. The infant's anterior fontanel is sunken. Which additional information is a priority for the nurse to assess? Number of feeds in the last 24 hours Number of hours infant has slept in the last 24 hours Skin color and cap refill Number of wet diapers the in the last 24 hours
Number of wet diapers the in the last 24 hours
The nurse assesses an infant with an undescended testis. The nurse should be alert for which symptom? abnormal lower extremity reflexes history of frequent emesis bulging in the inguinal area poor weight gain
bulging in the inguinal area
The birth parent of an infant with myelomeningocele asks if the child is likely to have any other defects. The nurse responds based on the understanding that myelomeningocele is commonly associated with which disorder? excessive cerebrospinal fluid within the cranial cavity abnormally small head congenital absence of the cranial vault overriding of the cranial sutures
excessive cerebrospinal fluid within the cranial cavity
During a well-baby visit, a 2-month-old infant receives a diphtheria, tetanus toxoids, and acellular pertussis (DTaP) vaccine, inactivated poliovirus vaccine, hepatitis B vaccine, pneumococcal vaccine, and Haemophilus influenzae b (Hib) vaccine. The parents ask why the baby must have the Hib vaccine. How does the nurse respond? "This vaccine prevents infection by the poliovirus." "This vaccine protects against serious bacterial infections, such as meningitis." "This vaccine prevents infection by the hepatitis B virus, which can cause liver damage." "This vaccine prevents susceptible children from getting chickenpox or smallpox."
"This vaccine protects against serious bacterial infections, such as meningitis."
A parent brings a 2-month-old infant to the clinic for a well-baby checkup. To best assess the interaction between the parent and infant, the nurse should observe them: as the infant plays. as the infant sleeps. as the parent feeds the infant. as the parent rocks the infant.
as the parent feeds the infant.
Which instruction would be most appropriate for the nurse to include in the teaching plan for the parent of a 1-year-old child who is to receive iron therapy with ferrous sulfate drops? Mix the drops with a cup of milk. Put the drops in the child's mouth, and then follow with juice. Put the drops in the child's mouth, and then follow with milk. Dilute the drops with water, and put them in the child's mouth.
Put the drops in the child's mouth, and then follow with juice.
The nurse implements strategies to reduce pain associated with vaccinations. Which intervention should the nurse employ? Use a 5/8-inch (1.6-cm) needle. Simultaneously administer vaccines at separate sites with a second nurse. Aspirate to verify needle placement. Tell the parent to breastfeed right before the vaccines are administered.
Simultaneously administer vaccines at separate sites with a second nurse.
The parent of a 12-month-old child expresses concern about the effects of the child's frequent thumb-sucking. After the nurse provides instruction on this topic, which response by the parent indicates that teaching has been effective? "Thumb-sucking should be discouraged at age 12 months." "I'll give my baby a pacifier instead." "Sucking is important to the baby." "I'll wrap the baby's thumb in a bandage."
"Sucking is important to the baby."
The nurse is caring for an infant diagnosed with nonorganic failure to thrive. Which action should be included in the plan of care for the infant? Suggesting to the infant's caregiver to continue to try to feed the infant even when the infant is crying. Weighing the unclothed infant at the same time every day. Reporting the caregiver to social services for suspected abuse. Requiring the caregiver to attend a community support group prior to discharge.
Weighing the unclothed infant at the same time every day.
Which serum electrolytes findings should the nurse expect to find in an infant with persistent vomiting? K+, 3.2; Cl-, 92; Na+, 120 K+, 3.4; Cl-, 120; Na+, 140 K+, 3.5; Cl-, 90; Na+, 145 K+, 5.5; Cl-, 110; Na+, 130
K+, 3.2; Cl-, 92; Na+, 120
A nurse is teaching the parents of an infant with clubfeet about cast care. Which statement by the parent indicates the need for further teaching? "I hope this cast will cure the feet in the next several weeks." "I know I will have to be careful when changing the diapers." "I will have to be careful how I hold the baby." "Immunizations will have to be delayed until the casts come off."
"Immunizations will have to be delayed until the casts come off."
A parent is concerned about spoiling a 2-month-old child by picking up the child each time the child cries. Which suggestion should the nurse offer? "If the baby's diaper is dry, leave the baby alone to fall asleep." "Continue to pick up the crying baby because young infants need cuddling and holding to meet their needs." "Leave your baby alone for 10 minutes. If the crying hasn't stopped then, pick up the baby." "Crying at this age indicates hunger. Try feeding when your baby cries."
"Continue to pick up the crying baby because young infants need cuddling and holding to meet their needs."
At a 6-month well-child check an infant has a high fever and cold symptoms and is diagnosed with otitis media. The child is scheduled to receive their 6-month immunizations. The parent asks the nurse if the child will receive them. What is the nurse's best response? "Your child will receive just the hepatitis immunization today because they're so sick." "Make an appointment to come back to get your child's immunizations when they've finished the antibiotics." "Your child must be free of infection for 6 months before they can resume their immunizations." "Your child should have a pneumonia shot today instead."
"Make an appointment to come back to get your child's immunizations when they've finished the antibiotics."
The nurse assesses a 4-month-old infant diagnosed with possible intussusception. The nurse should expect the parent to relate which information about the infant's crying and episodes of pain? constant accompanied by leg extension intermittent with knees drawn to the chest shrill during ingestion of solids intermittent while being held in the parent's arms
intermittent with knees drawn to the chest
The nurse works with the health care team to establish a policy regarding sleep positions for infants with gastroesophageal reflux. What information should the nurse search for first? policies from other hospitals data from retrospective studies published national standards expert opinions
published national standards
The nurse is caring for an infant that is awaiting cardiac surgery to correct a congenital heart defect. Which assessment findings does the nurse determine is an early indicator that the infant is developing heart failure? respiratory rate 70 breaths/minute poor weight gain sleeping heart rate 168 beats/minute diminished breath sounds
sleeping heart rate 168 beats/minute
The nurse teaches the parent of an infant who has had a surgical repair for a cleft lip about the use of elbow restraints at home. The nurse determines that the teaching has been successful when the parent makes which statement? "We will only remove the restraints one at a time to check the skin under them for redness." "We will keep the restraints on during the day while they are awake, but take them off when we put them to bed at night." "After we get home, we will not have to use the restraints because our child does not suck on their hands or fingers." "We will be sure to keep the restraints on all the time until we come to see the primary care provider for a follow-up visit."
"We will only remove the restraints one at a time to check the skin under them for redness."
