NCLEX 10000 Infant
A 6-month-old has had a pyloromyotomy to correct a pyloric stenosis. Three days after surgery, the parents have placed their infant in his own infant seat (see figure). What should the nurse do? a) Tell the parents they have positioned their infant correctly. b) Reposition the infant to the left side. c) Ask the parents to put the infant back in his crib. d) Remind the parents that the infant cannot use a pacifier now.
Tell the parents they have positioned their infant correctly. Correct Explanation: Following pyloromyotomy the infant should be positioned with the head elevated and slightly on the right side to promote gastric emptying; the parents have positioned their infant correctly. The infant should be positioned on the right side, not the left side.
When choosing nightclothes for an infant with atopic dermatitis, which of the following suggestions would be best? a) A diaper and short-sleeved shirt. b) One-piece cotton pajamas with long sleeves. c) Two-piece flannel pajamas with short sleeves. d) A woolen sleeper with feet and mittens.
One-piece cotton pajamas with long sleeves. Correct Explanation: Atopic dermatitis results in pruritus. The infant's skin should be covered as completely as possible to keep him from scratching himself. Cotton is the preferred material because it allows the skin to breathe and moisture to evaporate
Three weeks after the application of a spica cast following surgery, the mother calls the nurse because the infant's toes are swollen and cool to the touch. The nurse should instruct the mother to do which of the following? a) Have the child fitted for a larger cast. b) Put more cotton wadding to line the casting. c) Inspect the area for an infection. d) Place the child's legs in a lowered position.
Have the child fitted for a larger cast. Correct Explanation: Infants grow rapidly and may require application of a larger cast. A cast adequate for an infant after surgery may be outgrown in less than 1 month. The cast becomes too tight, impairing circulation evidenced by toe swelling and coolness to touch.
When teaching the family of an older infant who has had a spica cast applied for developmental dysplasia of the hip, which information should the nurse include when describing the abduction stabilizer bar? a) It can be adjusted to a position of comfort. b) It adds strength to the cast. c) It is used to lift the child. d) It is necessary to turn the child.
It adds strength to the cast. Correct Explanation: The abduction bar is incorporated into the cast to increase the cast's strength and maintain the legs in alignment. The bar cannot be removed or adjusted, unless the cast is removed and a new cast is applied.
Two parents who are arguing in their infant's room, with voices raised and getting louder, start to hit each other. The infant is crying. Which action should the staff nurse take next? a) Try to reason with both of the parents. b) Call security to come and break up the fight. c) Remove the infant from the room. d) Ask one of the parents to leave the room.
Remove the infant from the room. Correct Explanation: The situation is escalating, and the nurse's priority is to protect the infant from harm. Therefore, removal of the infant from this situation should be the first action by the nurse.
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? a) Have a close friend keep the infant for a few days. b) Talk quietly to the infant while he is awake. c) Limit holding the infant to feeding times. d) Play music in his room for most of the day and night.
Talk quietly to the infant while he is awake. Correct Explanation: Infants are sensitive to stress in their caretakers. The best way to handle an anxious infant is to talk quietly, thereby soothing the infant
A 9-month-old infant whose parents have emigrated from Mexico presents in the clinic with severe dehydration from vomiting. The infant was seen in the clinic just 3 days ago for a well-child visit, but now the family seems very distrustful of the health care team. The nurse should ask the parents: a) "Has immigration been causing you problems?" b) "Did anything concern you about your last visit?" c) "Are you afraid your baby will be taken from you?" d) "Have you been speaking with a healer?"
"Did anything concern you about your last visit?" Correct Explanation: In order to reestablish trust, the nurse should first try to determine if something happened at the last visit that was upsetting for the family
A 10-month-old infant is admitted with a harsh, barking cough and respiratory stridor. What are the most appropriate precautions for the nurse to follow when caring for the child? a) Place the child in a private room. b) Use an isolation gown and gloves in the room. c) Wear a mask when caring for the child. d) Wear gloves with direct care.
Use an isolation gown and gloves in the room. Explanation: According to the Centers for Disease Control and Prevention and the Public Health Agency of Canada, croup in infants requires contact isolation.
The nurse teaches the parents of an infant who has had surgery to correct imperforate anus how to position the infant to prevent tension on the perineum. The nurse determines more teaching is need when the parents put the infant in which position? a) right side, with hips elevated b) left side, with hips elevated c) abdomen, with legs pulled up under the body d) back, with legs suspended at a 90-degree angle
abdomen, with legs pulled up under the body Correct Explanation: When placed on the abdomen, a neonate pulls the legs up under the body, which puts tension on the perineum. Therefore, after surgery, the neonate should be positioned either supine with the legs suspended at a 90-degree angle or on either side with the hips elevated
A mother brings her 2-month-old infant to the clinic for a well-baby checkup. To best assess the interaction between the mother and infant, the nurse should observe them: a) as the infant sleeps. b) as the mother feeds the infant. c) as the mother rocks the infant. d) as the infant plays.
as the mother feeds the infant. Correct Explanation: The nurse can best assess mother-infant interaction during feeding, such as by observing how closely the mother holds the infant and how she looks at the infant's face. These behaviors help reveal the mother's anxiety level and overall feelings for the infant. The infant's posture and response during feeding provide clues to the infant's comfort level and feelings.
After teaching a mother about tests performed to monitor the success of her infant's treatment for congenital hypothyroidism, the nurse should determine that the teaching was effective when the mother states that the child will need frequent blood tests and regular assessment of what? a) Metabolic rate. b) Muscular coordination. c) Blood electrolyte levels. d) Bone age.
Bone age. Explanation: A child with congenital hypothyroidism who is receiving thyroid replacement therapy should be regularly assessed for blood levels of thyroxine and triiodothyronine and also undergo frequent bone age surveys to ensure optimum growth. Results of bone age surveys should demonstrate growth, indicating that the medication was adequate and effective.
When obtaining the nursing history from the mother of an infant with suspected intussusception, which question would be most helpful? a) "Is your child eating normally?" b) "When was the last time your child urinated?" c) "What do the stools look like?" d) "Has your child had any episodes of vomiting?"
"What do the stools look like?" Correct Explanation: For the infant with intussusception, stools characteristically have the appearance of currant jelly because of the intestinal inflammation and hemorrhage resulting from intestinal obstruction. These stools occur later in the course of the disease process.
A 9-month-old, well-nourished boy who lives with his extensive extended family tests positive for tuberculosis. What is a risk factor for tuberculosis in this child? a) Being in the 95th percentile for height and weight. b) Having a mother who did not receive prenatal care until the second trimester of her pregnancy. c) Being male. d) Being an infant.
Being an infant. Correct Explanation: Infants are more susceptible to tuberculosis because of a diminished resistance to infection due to an immature immune system. In later childhood and adolescence, morbidity and mortality are higher in females than males.
Which finding would be most indicative of hydrocephalus in an infant? a) Increased blood pressure. b) A pulsating fontanel. c) A positive glabellar reflex. d) Sunsetting eyes.
Sunsetting eyes. Explanation: Sunsetting eyes, or downward deviations of the irises, are a sign of hydrocephalus.
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? a) Reporting the parents to social services for suspected abuse b) Weighing the unclothed infant at the same time every day c) Suggesting to the infant's mother to continue to try to feed the infant even when the infant is crying d) Requiring the parents to attend a community support group prior to discharge
Weighing the unclothed infant at the same time every day Correct Explanation: Daily weights are an appropriate intervention for an infant with failure to thrive. It would be inappropriate for the nurse to encourage the mother to continue to try to feed the infant when crying because the infant may develop further aversion to eating. It is also inappropriate to assume that abuse has taken place; there is no information in the stem to suggest this. The parents would benefit from a community support group; however, the nurse cannot require the parents to attend a community support group prior to discharge.
An infant was taken from the ward by its parents without the knowledge of the nurses on the ward. The charge nurse conducts a performance improvement process to determine which of the following statements? a) conducting root cause analysis. b) requesting that a documented expert in the field perform a review. c) evaluating a single incident that resulted in an unanticipated outcome. d) randomly observing client care without advance warning.
conducting root cause analysis. Correct Explanation: Root cause analysis is used to gather information about factors that contribute to a problem (root causes) so that the nurse can identify ways to correct the problem.
An 8-month-old infant is admitted to the pediatric unit following a fall from his high chair. The child is awake, alert, and crying. The nurse should know that a brain injury is more severe in children because of: a) a slightly thicker cranium b) intracranial hypotension c) cerebral hyperemia d) increased myelination
cerebral hyperemia Correct Explanation: Cerebral hyperemia (excess blood in the brain) causes an initial increase in intracranial pressure in the head of an injured child. The brain is less myelinated in a child and more easily injured than an adult brain.
Which type of restraint is best for the nurse to use for a child in the immediate postoperative period after cleft palate repair? a) elbow restraints b) body restraints c) wrist restraints d) safety jacket
elbow restraints Correct Explanation: Recommended restraints for a child who has had palate surgery are elbow restraints. They minimize the limitation placed on the child but still prevent the child from injuring the repair with fingers and hands
When teaching 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? a) entire hand b) fingertips c) heel of the hand d) palm of the hand
heel of the hand Correct Explanation: Back slaps are delivered rapidly and forcefully with the heel of the hand between the infant's shoulder blades.
A 10-month-old child with phenylketonuria (PKU) is being weaned from breast-feeding. When teaching the parents about the proper diet for their child, the nurse should stress the importance of restricting meats and dairy products because: a) they are difficult for clients with PKU to digest. b) they are not well tolerated in children with PKU until after age 2. c) they contain high levels of phenylketones, which inhibit muscle growth. d) they contain high levels of phenylalanine.
they contain high levels of phenylalanine. Correct Explanation: PKU is an inherited disorder characterized by the inability to metabolize phenylalanine, an essential amino acid. Phenylalanine accumulation in the blood results in central nervous system damage and progressive intellectual disability. However, early detection of PKU and dietary restriction of phenylalanine can prevent disease progression. Intake of high-protein foods, such as meats and dairy products, must be restricted throughout life because they contain large amounts of phenylalanine
Which of the following nursing interventions is most important postoperatively for an infant who has received a ventriculoperitoneal shunt? a) Allowing the infant to rest undisturbed. b) Providing age-appropriate diversionary activities. c) Initiating oral feedings. d) Monitoring intake and output.
Monitoring intake and output. Correct Explanation: In the postoperative period, intake and output are carefully monitored to prevent fluid overload that could lead to increased intracranial pressure.
The mother of an infant with flat feet asks the nurse what she can do about the problem. Which response from the nurse is the most appropriate? a) "Flat feet cause other orthopedic problems in infants." b) "Corrective shoes will strengthen the arches of the feet." c) "Nightly exercises will help make the arches supple." d) "Infants have a fat pad below the arch, making it look like flat feet."
"Infants have a fat pad below the arch, making it look like flat feet." Explanation: Infants have a fat pad below the arch, giving the appearance of flat feet. Exercises will not correct flat feet. Flat feet cause no other orthopedic problems in infants. Corrective shoes will have no effect on strengthening the arches of the child's feet
When assessing a 4-month-old infant diagnosed with possible intussusception, the nurse should expect the parent to relate what information about the infant's crying and episodes of pain? a) intermittent while being held in the parent's arms b) intermittent with knees drawn to the chest c) shrill during ingestion of solids d) constant accompanied by leg extension
intermittent with knees drawn to the chest Correct Explanation: The infant with intussusception experiences acute episodes of colic-like abdominal pain. Typically, the infant screams and draws the knees to the chest. Between these episodes of acute abdominal pain, the infant appears comfortable and normal.
A nurse is teaching child care classes for adolescent mothers. To enhance the adolescents' understanding of infant safety, the nurse would suggest that the mother: a) discuss infant safety with the pediatrician. b) attend a lecture about poison control. c) review a video about pregnancy prevention. d) Crawl around on the floor looking for cotential hazards from the eyes of an infant.
Crawl around on the floor looking for cotential hazards from the eyes of an infant. Correct Explanation: Crawling on the floor is a participative activity that can help promote understanding of infant safety in relation to the infant's perspective.
A nurse is assessing the chest of a 4-month-old infant. The nurse identifies the ratio of the anteroposterior-to-lateral diameter as 1:2. Which of the following actions should the nurse take next? a) Obtain an order for a chest X-ray b) Observe for substernal retractions c) Auscultate for adventitious lung sounds d) Document the findings in the client's medical record
Document the findings in the client's medical record Correct Explanation: This is a normal finding and requires no further action.
An infant, age 6 weeks, is brought to the clinic for a well-baby visit. To assess the fontanels, how should the nurse position the infant? a) Seated upright b) In the left lateral position c) Supine d) Prone
Seated upright Explanation: For the most accurate results, the nurse should seat the infant upright to assess the fontanels and should perform this assessment when the infant is quiet. Pressure from postural changes or intense crying may cause the fontanels to bulge or seem abnormally tense.
Which safeguard is necessary when administering I.V. fluid to an infant? a) Use of an infusion pump to regulate the flow rate b) Use of a micro drop (mini drip) infusion set c) Use of a gravity infusion set d) Administration of fluid at the slowest possible rate by infant weight
Which safeguard is necessary when administering I.V. fluid to an infant? You selected: Use of an infusion pump to regulate the flow rate Correct Explanation: Use of an infusion pump to regulate the flow rate is the appropriate safeguard, because infants and children with compromised cardiopulmonary status are particularly vulnerable to I.V. fluid overload.
A nurse is reviewing a teaching plan with parents of an infant undergoing repair for a cleft lip. Which instructions are the most appropriate for the nurse to give? Select all that apply. a) Sit the infant up for each feeding. b) Give the infant extra care and support. c) Loosen the arm restraints every 4 hours. d) Offer a pacifier as needed. e) Clean the suture line after each feeding by dabbing it with saline solution.
• Give the infant extra care and support. • Sit the infant up for each feeding. • Clean the suture line after each feeding by dabbing it with saline solution. Correct Explanation: The nurse should instruct the parents to feed the infant in the upright position with a syringe and attached tubing to prevent stress to the suture line from sucking. In addition, to prevent crusts and scarring, the suture line should be cleaned after each feeding by dabbing it with half-strength hydrogen peroxide or saline solution. The parents should give the infant extra care and support because he/she cannot meet emotional needs by sucking. Extra attention may also prevent crying, which stresses the suture line. Offering a pacifier is not appropriate. Pacifiers should not be used during the healing process because they stress the suture line. Arm restraints keep the infant's hands away from his/her mouth; they should be loosened every 2 hours, not every 4 hours.
A nurse at the family clinic receives a call from the mother of a 5-week-old infant. The mother states that her child was diagnosed with colic at the last checkup. Unfortunately, the symptoms have remained the same. Which teaching instructions are appropriate? Select all that apply. a) Provide small but frequent feedings to the infant. b) Offer a pacifier if it is not time for the infant to eat. c) Immediately bring the infant to the emergency department. d) Soothe the child by humming and rocking. e) Burp the infant adequately after feedings. f) Position the infant on the back after feedings.
• Soothe the child by humming and rocking. • Burp the infant adequately after feedings. • Provide small but frequent feedings to the infant. • Offer a pacifier if it is not time for the infant to eat. Correct Explanation: Colic consists of recurrent paroxysmal bouts of abdominal pain and is fairly common in infants. It usually disappears by age 3 months. Rocking, riding in a car, humming, and offering a pacifier may be used to comfort the infant. Decreasing gas formation by frequent burping, giving smaller feedings more frequently, and positioning the infant in an upright seat are also appropriate teaching.
A 5-month-old infant is brought to the clinic by his parents because he "cries too much" and "vomits a lot." The infant's birth weight was 6 lb, 10 oz (3,005 g), and his current weight is 7 lb, 4 oz (3,289 g), falling below the 5th percentile on a standard growth chart. Which of the following data should the nurse identify as the priority? a) Pattern of weight gain. b) Feeding pattern. c) Frequency of regular checkups. d) Family dynamics.
Feeding pattern. Correct Explanation: Because the infant falls below the 5th percentile on a standard growth chart, the nurse should consider failure to thrive, a term applied to an infant who is not growing at an acceptable rate. Information about feeding patterns, including types and amounts of food, is needed to determine the cause of failure to thrive. If a child does not receive sufficient calories, growth slows. Whether or not the infant has received regular checkups is important but not the priority because that information alone does not provide evidence or substantiation about the infant's growth patterns. The infant's pattern of weight gain is important but not the priority. Rather, the infant's pattern of weight gain provides valuable and useful information over a period of time.
