NCLEX-RN Passpoint Infant
A charge nurse is making client care assignments for the day. Which client would be mostappropriate to assign a licensed practical nurse (LPN)? 1-month-old infant with bronchiolitis with a respiratory rate of 60 4-year-old child with nephrotic syndrome with 4+ protein in the urine 6-year-old child 2-day post-op appendectomy with a surgical drain 6-month-old infant with pneumonia on oxygen
6-year-old child 2-day post-op appendectomy with a surgical drain
The health care provider (HCP) prescribes an intravenous infusion of 5% dextrose in 0.45 normal saline to be infused at 2ml/kg per hour in an infant who weighs 9 lb (4.1 kg). How many milliliters per hour of the solution should the nurse infuse? Round to one decimal place.
8.2
The nurse is caring for an infant diagnosed with thrush. Which instruction would the nurse give to a client's mother who will be administering nystatin oral solution? Mix the drug with small amounts of formula in bottle. Administer the drug right after meals by dabbing the solution to the sites. Administer the drug right before meals by using a gauze pad. Administer half the dose before and half after a feeding.
Administer the drug right after meals by dabbing the solution to the sites.
The breastfeeding mother of a 1-month-old diagnosed with cow's milk sensitivity asks the nurse what she should do about feeding her infant. Which recommendation would be mostappropriate? Change to a soy-based formula exclusively, and begin solid foods. Continue to breastfeed, but eliminate all milk products from your own diet. Discontinue breastfeeding, and start using a predigested formula. Limit breastfeeding to once per day, and begin feeding an iron-fortified formula.
Continue to breastfeed, but eliminate all milk products from your own diet.
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? twice-weekly clinic appointments enrollment in community parenting classes weekly visits by a community health nurse daily phone calls from the hospital nurse
weekly visits by a community health nurse
Which action should the nurse include when developing the plan of care for a neonate prior to surgical repair of a myelomeningocele?
Cover the defect with moist, sterile saline dressings.
A normal, healthy 2-month old infant is brought to the clinic for the first diphtheria, tetanus, and acellular pertussis (DTaP) immunization. Which route is appropriate to administer this vaccine? intradermal subcutaneous oral IM
IM
The parents of a healthy infant request information about advance directives. The nurse's best response is to ask open-ended questions to understand the parents' concerns. reassure the parents that advance directives are needed only for those who are likely to become ill. inform the parents that advance directives are a legal document and need a notary. provide the parents with a brochure about advance directives.
ask open-ended questions to understand the parents' concerns.
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 hours infant has slept in the last 24 hours Number of wet diapers the in the last 24 hours Skin color and cap refill Number of feeds in the last 24 hours
Number of wet diapers the in the last 24 hours
After teaching the parents of an infant with clubfoot requiring application of a plaster cast how to care for the cast, which statement would indicate that the parents have understood the teaching? "If the cast becomes soiled, we will clean it with soap and water." "We will check the color and temperature of the toes of the casted leg frequently." "The petals on the edge of the cast can be removed after the first 24 hours." "We will elevate the leg with the cast on pillows, so the leg is above heart level."
"We will check the color and temperature of the toes of the casted leg frequently."
A parent asks the nurse why a 10-month-old infant gets otitis media more frequently than a 10-year-old child. How should the nurse respond? "Infants are unable to blow their own noses." "Infants under one year have immature immune systems." "Pressure builds up in the ear canal when infants lie flat." "An infant's eustachian tubes are shorter."
"An infant's eustachian tubes are shorter."
A first-time mother is concerned that her 6-month-old infant is not gaining enough weight. What should the nurse tell the mother? "The baby will eat what he needs." "You need to make sure the baby finishes each bottle." "Using a body mass index (BMI) for age growth chart is the best way to assess proper weight gain." "Birth weight doubles by 6 months of age."
"Birth weight doubles by 6 months of age."
A nurse is teaching the parents of an infant with cystic fibrosis about chest percussion therapy. Which statement by the nurse is most accurate in explaining the rationale for using chest percussion on infants with cystic fibrosis? "Chest percussion helps clear secretions out of the lungs." "Chest percussion is needed everyday to prevent infection." "Chest percussion is needed only when the child is ill." "Chest percussion is used as an adjunct to nebulizer treatments."
"Chest percussion helps clear secretions out of the lungs."
A parent calls the clinic to report their 9-month-old infant has had 5 soft to loose stools today, has a decreased appetite, but is alert and playing. Which advice is most appropriate for the nurse to give the parent? "Feed your infant clear liquids only." "Continue your infant's normal feedings." "Call back if your infant has 10 stools in 1 day." "Notify your infant's daycare of his illness."
"Continue your infant's normal feedings."
A 4-month-old infant has been carried into the emergency department after falling off the parents' bed and hitting the head on the floor. What should the nurse do first? Assess the infant's vital signs in the triage area and instruct the family to wait until their names are called. Move the family to an area where an assessment can be completed and call for a physician. Call child protective services because of suspected child endangerment. Notify the supervisor that an operating room is needed because the physician will want to insert a ventriculoperitoneal (VP) shunt.
Move the family to an area where an assessment can be completed and call for a physician.
A nurse caring for a child diagnosed with patent ductus arteriosus palpates a very forceful and bounding pulse. Which interventions should the nurse provide after this assessment? Documenting the finding. Administering furosemide as ordered. Applying oxygen at 6 L/min. Calling the physician immediately.
Documenting the finding.
Assessment of a 6-week-old infant reveals weight and length in the 50th percentile for his age and a head circumference at the 95th percentile. What should the nurse do first? Obtain a written consent for transillumination. Assess motor and sensory function of the legs. Examine the fontanels and sutures. Advise the mother of the need for follow-up in 1 month.
Examine the fontanels and sutures.
A nurse is preparing to administer an I.V. containing dextrose 10% in ¼ normal saline solution to a 6-month-old infant. The nurse should select which tubing to safely administer the solution? I.V. tubing with a macrodrip chamber I.V. tubing with a volume-control chamber I.V. tubing with a special filter standard I.V. tubing used for adults
I.V. tubing with a volume-control chamber
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? IV administration of lactated Ringer's neurologic assessment with the Glasgow Coma Scale insertion of a Foley indwelling catheter application of telemetry monitoring
IV administration of lactated Ringer's
The nurse is planning care with the parents of a 4-month-old infant with heart failure and congenital heart disease. The parents report that their child tires easily. Which intervention is a priority for this child? Prevent infection. Restrict the child's movements. Add layers of clothing Increase the number of rest periods.
Increase the number of rest periods.
Which nursing intervention is most important postoperatively for an infant who has received a ventriculoperitoneal shunt? Initiate oral feedings. Monitor intake and output. Provide age-appropriate diversionary activities. Allow the infant to rest undisturbed.
Monitor intake and output.
The mother of a 9-month-old infant asks about adding new foods to his diet. The child is being breast-fed and takes formula and cereal when at the sitter's. What should the nurse instruct the mother to do? Mix new foods with more familiar foods. Mix new foods with formula or breast milk. Offer new foods after giving formula or breast milk. Offer new foods one at a time.
Offer new foods one at a time.
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? Perform a neurologic assessment. Assess bowel sounds. Palpate for an enlarged liver. Review recent urinary output.
Perform a neurologic assessment.
An infant is brought to the emergency department. The infant is limp and has central cyanosis, a heart rate of 60 beats/minute, and a respiratory rate of 12 breaths/minute. The parents state that they have an advance directive for their infant, who has a terminal illness. A nurse's initial action should be to: contact the nursing supervisor for assistance. provide palliative care for the infant and the parents. administer oxygen to the infant while awaiting the physician's orders. ask to see a copy of the advance directive.
ask to see a copy of the advance directive.
While attending a support group, the parents of a child with hemophilia become concerned because they heard stories about how many children with hemophilia have died from acquired immunodeficiency syndrome (AIDS). They ask the nurse how these children got the AIDS virus. The nurse bases the response on which as the most likely route of transmission of AIDS to these children? exposure in the waiting room to children with AIDS attending the same hematology clinic contamination of the factor VIII replacement received during bleeding episodes casual contact with a child testing positive for human immunodeficiency virus use of a contaminated needle to obtain a blood sample for type and crossmatching
contamination of the factor VIII replacement received during bleeding episodes
When developing 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? chaplain referral for psychological support schedule for daily home health care daily care required for the infant a list of available hospital services
daily care required for the infant
A nurse is teaching the parent of an infant. The nurse should instruct the parent to introduce the infant to solid foods at what age? 8 months 6 months 4 months 2 months
6 months
A 6-month-old on the pediatric floor has a respiratory rate of 68, mild intercostal retractions, and an oxygen saturation of 89%. The infant has not been feeding well for the last 24 hours and is restless. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the health care provider (HCP) with the recommendation for which treatment? starting oxygen. prescribing a chest CT scan. providing sedation. transferring the child to pediatric intensive care.
starting oxygen.
When teaching the mother of an infant who has received a temporary colostomy for treatment of Hirschsprung's disease about how the stoma should normally appear, the nurse should include which description about the stoma's appearance in the teaching? staying deep red in color changing to several shades of pink turning almost purple in color becoming dark brown in 2 months
staying deep red in color
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'm giving the baby iron-fortified formula and a fluoride supplement because our water isn't fluoridated."
The unlicensed assistive personnel (UAP) obtained vital signs on a 7-month-old infant and recorded the peripheral pulse as 85 beats/minute. The RN immediately reassesses the child's pulse and discovers the pulse is 115 beats/minute. What should the nurse teach the UAP about obtaining an accurate heart rate in an infant? "To assess a pulse in children, always assess the apical pulse." "To assess a pulse under age 1, you should check the brachial artery." "Here is a copy of normal heart rates in children so you can report abnormal findings." "Always assess the pulse rate after you take the blood pressure."
"To assess a pulse in children, always assess the apical pulse."
Before a routine checkup, an 8-month-old infant sits contentedly on the parent's lap, chewing on a toy. When preparing to examine this infant, what should the nurse plan to do first? Elicit the pupillary reaction. Auscultate the heart and lungs. Weigh the child. Measure the head circumference.
Auscultate the heart and lungs.
A dehydrated infant is receiving IV therapy. The parent tells the nurse about wanting to hold the infant but being afraid this might cause the IV line to become dislodged. How should the nurse respond? Encourage the parent to interact with the infant while lying in the bed. Provide a comfortable chair for the parent to hold the infant while connected to the IV. Place a restraint on the arm with the IV site so it cannot move or become dislodged. Temporarily disconnect the IV line so the parent can hold the child comfortably.
Provide a comfortable chair for the parent to hold the infant while connected to the IV.
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? Have a close friend keep the infant for a few days. Talk quietly to the infant while he is awake. Play music in his room for most of the day and night. Limit holding the infant to feeding times.
Talk quietly to the infant while he is awake.
After surgery to repair a cleft lip, an infant has a Logan bow in place. Which postoperative nursing action is appropriate?
holding the infant semi-upright during feedings
An infant is brought to the clinic with a possible diagnosis of Wilms' tumor. When obtaining the health history, which question should the nurse consider a priority to ask the parent? "Did the healthcare provider find a mass in the abdominal area?" "Does your baby have a pulsating anterior fontanel?" "Did your baby have a reddish jelly-like bowel movement?" "Does your baby have projectile vomiting after feeding?"
"Did the healthcare provider find a mass in the abdominal area?"
The mother of an infant with iron deficiency anemia asks the nurse what she could have done to prevent the anemia. The nurse should teach the mother that it is helpful to introduce solid foods into the infant's diet at which age? 6 months 10 months 8 months 3 months
6 months
At a previous visit, the parents of an infant with cystic fibrosis received instruction in the administration of pancrelipase. At a follow-up visit, which finding in the infant suggests that the parents require more teaching about administering the pancreatic enzymes? liquid stools fatty stools bloody stools normal stools SUBMIT ANSWER
fatty stools
The nurse is caring for an infant with hypospadias. Identify the area where the nurse would assess for this condition.
Underside of penis.
A 10-month-old infant with tetralogy of Fallot (TOF) experiences an cyanotic episode. To improve oxygenation during such an episode, the nurse should place the infant in which position? Fowler's knee-to-chest Trendelenburg's prone
knee-to-chest
The nurse needs to assess an infant's height to determine if the infant is meeting appropriate growth and development parameters. To obtain the most accurate measurement of an infant's height (length), the nurse measures the: recumbent height with the infant lying on the side. recumbent height with the infant supine. standing height with the infant held upright. recumbent height with the infant prone.
recumbent height with the infant supine.
What liquid does the nurse recommend the parents of a 1½-month-old infant with hypothyroidism use to administer levothyroxine with? large amount of water infant's bowl of cereal milk or orange juice small amount of formula or breast milk
small amount of formula or breast milk
Which finding indicates that the infant has adequately evacuated the barium after undergoing a barium enema? stools that progress from clay-colored to brown bowel sounds of 30 per minute absence of fecal mass in the lower abdomen stool guaiac that is negative
stools that progress from clay-colored to brown
The nurse is caring for a 3-month-old infant, who had a cleft palate and cleft lip surgical repair. Which assessment data would indicate a postoperative complication from the surgery? intermittent crying suture line surrounded by erythema Logan bar in place swollen suture line
suture line surrounded by erythema
When teaching the mother of an infant diagnosed with congenital hypothyroidism about daily oral levothyroxine sodium therapy, which manifestation should the nurse include as possibly indicating an overdose? constipation anorexia sweating sleepiness
sweating
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 inside of the infant's mouth.
An infant is admitted to the hospital with dehydration secondary to viral gastroenteritis. Which room assignment is the most appropriate for this infant? a semiprivate room with an 8-year-old child who has had an appendectomy a semiprivate room with a 4-year-old child with leukemia a semiprivate room with a 10-year-old child with a closed head injury a private room
a private room
Which of the following actions is correct when the student nurse assesses the fontanels of a 6-week-old infant? probing the fontanels firmly while the infant is prone on the table palpating the fontanels gently while the infant sits on the parent's lap 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
A nurse is obtaining the history of an infant with suspected acute otitis media. What should the nurse ask the parent about? position of the infant when taking a bottle immunization status of the infant thorough drying of the infant's ears after a bath covering of the infant's ears when out in the cold
position of the infant when taking a bottle
The nurse works with the health care team to establish a policy regarding sleep positions for infants with gastroesophageal reflux. What information should the nurse search for first? data from retrospective studies policies from other hospitals published national standards expert opinions
published national standards
After teaching 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? "After we get home, we will not have to use the restraints, because our child does not suck on his hands or fingers." "We will keep the restraints on during the day while he is awake, but take them off when we put him to bed at night." "We will only remove the restraints one at a time to check the skin under them for redness." "We will be sure to keep the restraints on all the time until we come to see the health 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."
The mother of an infant being admitted to the hospital is crying and very upset. Which statement by the nurse would be most therapeutic? "Everyone here will take care excellent care of your infant." "You did the right thing bringing him here when you did." "What's making you cry right now?" "Please don't worry, everything's going to be all right."
"What's making you cry right now?"
The nurse teaches the father of an infant hospitalized with gastroenteritis about the next step of the treatment plan once the infant's condition has been controlled. The nurse should determine that the father understands when he explains that which intervention will occur with his infant? Formula and juice will be offered. Blood will be drawn daily to test for anemia. The infant will receive clear liquids for a period of time. The infant will be allowed to go to the playroom.
The infant will receive clear liquids for a period of time.
A parent brings a 2-month-old infant to the clinic for a well-baby checkup. Which setting would be best for the nurse to assess the interaction between parent and infant? as the parent feeds the infant as the infant watches a mobile as the parent rocks the infant as the infant sleeps
as the parent feeds the infant
The physician suspects tracheoesophageal fistula in a 1-day-old neonate. Which nursing intervention is most appropriate for this child? elevating the neonate's head for 1 hour after feedings elevating the neonate's head and giving nothing by mouth giving the neonate only glucose water for the first 24 hours avoiding suctioning unless cyanosis occurs
elevating the neonate's head and giving nothing by mouth
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? intermittent while being held in the parent's arms intermittent with knees drawn to the chest constant accompanied by leg extension shrill during ingestion of solids
intermittent with knees drawn to the chest
A physician orders an intravenous infusion of dextrose 5% in quarter-normal saline solution (D5.25 NSS) to be infused at 7 ml/kg/hour for a 10-month-old infant. The infant weighs 22 lb (10 kg). How many milliliters of the ordered solution would the nurse infuse each hour? Record your answer using a whole number.
70 ml/hr
The nurse is preparing to discharge a 9-month-old infant recovering from gastroenteritis and dehydration and teaching a parent regarding the infant's dietary and fluid requirements. Which of the following statements made by the parent indicates that further instruction is required? "We will bring my child back to the primary care provider if the diarrhea begins." "We will monitor the baby for any signs of dehydration." "We may need to consider giving the child a lactose-free formula if diarrhea continues." "We can go ahead and begin to the feed the baby whatever they want to eat and drink."
"We can go ahead and begin to the feed the baby whatever they want to eat and drink."
A nurse is assessing the family of an infant and observes that the parents are argumentative and appear fatigued. They indicate that the baby is not breastfeeding well and cries through the night. What would be the nurse's priority nursing diagnosis for this infant? parental sleep pattern disturbance related to the baby's feeding schedule altered role performance related to new responsibilities within the family altered nutrition (less than body requirements) related to difficulty sucking knowledge deficit related to normal infant growth and development
altered nutrition (less than body requirements) related to difficulty sucking
For an infant who's about to undergo a lumbar puncture, the nurse should place the infant in: a mummy restraint. a prone position, with the head over the edge of the bed. an arched, side-lying position, with the neck flexed onto the chest. an arched, side-lying position, avoiding flexion of the neck onto the chest.
an arched, side-lying position, avoiding flexion of the neck onto the chest.
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? fingertips palm of the hand heel of the hand entire hand
heel of the hand
