Pediatric: infant practice ?s

Three weeks after an infant receives a spica cast, the mother calls the nurse because the infant's toes are swollen and cool to the touch. What should the nurse instruct the mother 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.

Correct response: Have the child fitted for a larger cast. 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.The mother should keep the child's feet in a recumbent position. When feet are dependent in a cast, decreased venous return may occur. Reduced venous return along with decreased feet and leg movement subsequently leads to edema, which resolves when the feet are returned to a recumbent position.The cotton wadding used to line the cast does not shrink over time.If the child had surgery, the chances of infection are minimal after a 3- to 4-week period. In addition, other symptoms of infection, such as fever and possibly a hot spot on the cast, would be present.

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? Palpate for an enlarged liver. Assess bowel sounds. Perform a neurologic assessment. Review recent urinary output.

Correct response: Perform a neurologic assessment. Explanation: Failure to suck and swallow may indicate neurologic deterioration. Central nervous system assessment always takes priority over other body systems to rule out CNS involvement.

When teaching the mother of a child diagnosed with phenylketonuria (PKU) about its transmission, the nurse should use knowledge of which factor as the basis for the discussion? A. chromosome translocation B. chromosome deletion C. autosomal recessive gene D. x-linked recessive gene

Correct response: autosomal recessive gene Explanation: PKU is caused by an inborn error of metabolism. It is an autosomal recessive disorder that inhibits the conversion of phenylalanine to tyrosine. A form of Down syndrome, trisomy 21, is an example of a disorder caused by chromosomal translocation. Cri du chat is an example of a disorder caused by chromosomal deletion. Hemophilia A is an example of a disorder caused by an X-linked recessive gene.

A 4-month-old infant is diagnosed with congenital hypothyroidism and prescribed levothyroxine. When should the nurse teach the parents to administer the medication? A. with the nighttime formula B. 30 minutes after meals C. on an empty stomach D. regardless of meals

Correct response: on an empty stomach Explanation: Levothyroxine should be taken on an empty stomach to facilitate absorption. All the other responses could reduce absorption and cause subtherapeutic levels.

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

Correct response: Babinski's sign Explanation: A positive Babinski's sign involves dorsiflexion of the big toe and fanning of the other toes. Although normal in infants, this response is abnormal after about age 1 year or when walking begins.The stepping reflex occurs when an infant is held as though weight bearing with the feet on a surface and the infant steps along, raising one foot at a time.A plantar grasp reflex is characterized by flexion of the toes when a finger is placed against the base of the toes.A normal Galant reflex is initiated by stroking an infant's back alongside the spine. The hips should move toward the stimulated side.

In developing a security plan for a pediatric unit, a nurse must consider which factors? Select all that apply. A. identification of neonates, infants, toddlers, children, and adolescents at all times B. the facility's physical layout C. the climate in which the hospital is located D. available resources to obtain and maintain the security plan E. methods for educating all staff regarding the security plan

Correct response: A. identification of neonates, infants, toddlers, children, and adolescents at all times B. the facility's physical layout D. available resources to obtain and maintain the security plan E. methods for educating all staff regarding the security plan Explanation: When developing a security plan for a pediatric unit, the nurse should consider the identification of neonates, infants, toddlers, children, and adolescents; the facility's physical layout; available resources; and methods for educating staff. The nurse does not need to consider the climate in which the hospital is located.

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? A. Document that growth is occurring quickly. B. Obtain an order to administer a diuretic. C. Assess for signs of increased intracranial pressure. D. Teach the parent how to protect the child's head.

Correct response: C. Assess for signs of increased intracranial pressure. Explanation: Measuring head circumference is an important determinant of brain growth and potential neurologic function. A rapid increase in size is usually indicative of hydrocephalus. Other signs of increased intracranial pressure may be present. It is usually necessary to surgically place a shunt to relieve the pressure.

A nurse is developing a plan to teach a parent how to reduce an infant's risk of developing otitis media. Which direction should the nurse include in the teaching plan? A. Administer antibiotics whenever the infant has a cold. B. Place the infant in an upright position when giving a bottle. C. Avoid getting the infant's ears wet while bathing or swimming. D. Clean the infant's external ear canal daily.

Correct response: Place the infant in an upright position when giving a bottle. Explanation: Feeding an infant a bottle in an upright position reduces the pooling of formula or breast milk in the nasopharynx. Formula, in particular, provides a good medium for the growth of bacteria, which can travel easily through the short, horizontal eustachian tubes. Administering antibiotics whenever the infant has a cold, avoiding getting the ears wet, and cleaning the external ear canal daily don't reduce the risk of an infant developing otitis media.

A nurse admits an infant diagnosed with pyloric stenosis. What is the nurse's priority intervention? Weigh the infant. Check urine specific gravity. Place an I.V. catheter. Change the infant and weigh the diaper.

Correct response: Weigh the infant. Explanation: Weighing the infant would be done first so a baseline weight can be established and weight changes can be evaluated. After a baseline weight is obtained, an I.V. catheter can be placed because oral feedings generally aren't given. Infants with pyloric stenosis are usually dehydrated, so weighing the diaper or checking the specific gravity, though important, are not a priority.

The parents of a healthy infant request information about advance directives. The nurse's best response is to A. reassure the parents that advance directives are needed only for those who are likely to become ill. B. inform the parents that advance directives are a legal document and need a notary. C. provide the parents with a brochure about advance directives. D. ask open-ended questions to understand the parents' concerns.

Correct response: ask open-ended questions to understand the parents' concerns. Explanation: Asking open-ended questions about the parents' concerns will help the nurse understand why they are asking for information. Advance directives are rarely prepared for healthy infants. The parents' request for information may indicate distress, and the nurse should obtain more details before giving them information. It is not necessary for the parents to discuss this with a lawyer as the infant is healthy. Providing the parents with a brochure about advance directives would help the parents understand what they are, but the nurse must obtain additional information.

The mother of an infant with myelomeningocele asks if her baby is likely to have any other defects. The nurse responds based on the understanding that myelomeningocele is commonly associated with which disorder? A. excessive cerebrospinal fluid within the cranial cavity B. abnormally small head C. congenital absence of the cranial vault D. overriding of the cranial sutures

Correct response: excessive cerebrospinal fluid within the cranial cavity Explanation: Excessive cerebrospinal fluid in the cranial cavity, called hydrocephalus, is the most common anomaly associated with myelomeningocele. Microcephaly, an abnormally small head, is associated with maternal exposure to rubella or cytomegalovirus. Anencephaly, a congenital absence of the cranial vault, is a different type of neural tube defect. Overriding of the sutures, possibly a normal finding after a vaginal birth, is not associated with myelomeningocele. Remediation:

An infant undergoes surgery to correct an esophageal atresia and tracheoesophageal fistula. Which nursing diagnosis has the highest priority during the first 24 hours postoperatively? A. ineffective airway clearance B. imbalanced nutrition: less than body requirements C. impaired tissue perfusion D. risk for aspiration

Correct response: ineffective airway clearance Explanation: Ineffective airway clearance has the highest priority in the immediate postoperative period. The infant's airway must be carefully assessed, and frequent suctioning may be necessary to remove mucus while taking care not to pass the catheter as far as the suture line. The nurse should assess breath sounds, respiratory rate, skin color, and ease of breathing. Because of the risk of edema and airway obstruction, keep a laryngoscope and endotracheal intubation equipment readily available. There could be impaired tissue perfusion from the edema, but keeping the airway patent is the priority. The risk for aspiration is present, but a risk does not take priority over an actual nursing problem. Imbalanced nutrition can occur because the infant is unable to ingest any food—nutrients must be provided via enteral or parenteral nutrition—but this diagnosis does not have priority over the airway.

The nurse is admitting a newborn to the nursery. Report reveals that the newborn was slow to crown and delivery of the head and chin was difficult. For which complication would the nurse need to assess? shoulder dystocia immature lung function hypoglycemia small birth weight

Correct response: shoulder dystocia Explanation: This neonate exhibits findings of a post-term infant. Typically they are larger in size and more at risk for having shoulder dystocia. Immature lung function, hypoglycemia, and small birth weight are more common in pre-term infants.

A mother expresses concern that picking up the infant whenever he cries will spoil him. What is the nurse's best response? A. "Allow him to cry for no longer than 45 minutes, then pick him up." B. "Babies need comforting and cuddling; meeting these needs will not spoil him." C. "Babies this young cry when they are hungry; try feeding him when he cries." D. "If it seems as if nothing is wrong, do not pick him up; the crying will stop eventually."

Correct response: "Babies need comforting and cuddling; meeting these needs will not spoil him." Think of Erikson's stage of development: Trust versus mistrust Explanation: It is a common misconception that picking up an infant whenever he or she cries will spoil the child. Infants need to be cuddled and comforted when they are upset. Comforting may be as simple as feeding or changing a wet diaper.An infant typically cries because of a need, for example, being hungry, needing to be burped, or having a wet diaper. Responding to the infant's needs in a timely fashion by picking the infant up helps to develop trust. Allowing the infant to cry for 45 minutes would be inappropriate and too long to wait.Assuming that the infant is hungry each time he cries could lead to overfeeding.

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? A. "Call back if your infant has 10 stools in 1 day." B. "Feed your infant clear liquids only." C. "Continue your infant's normal feedings." D. "Notify your infant's daycare of his illness."

Correct response: "Continue your infant's normal feedings." Explanation: It is not unusual for infants to have several bowel movements per day, with breast-fed infants usually having more than formula-fed ones. If an infant has mild diarrhea lasting only one day with no change in energy level, the mother should be advised to continue the normal diet and to call back if the diarrhea continues or if the infant shows signs of dehydration. The nurse should teach the parent the symptoms of dehydration, such as decreased urine output, reduced tear production, or listlessness. There is no need to give the infant clear liquids only. Notifying the daycare about the infant's illness is important if the parent will be leaving the infant in their care, but it doesn't take priority.

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? A. "I hope my baby will come home from the hospital." B. "I know that this disease is serious and can lead to asthma." C. "My baby needs to be cured this time so it won't happen again." D. "My baby has been sick. A machine will help him breathe."

Correct response: "I know that this disease is serious and can lead to asthma." Explanation: By saying that bronchiolitis places the child at risk for developing asthma, the parent demonstrates understanding of the infant's condition. If diagnosed and treated promptly, most infants recover from the illness and return home. Infants typically don't have recurrences of bronchiolitis. Infants diagnosed with bronchiolitis rarely require mechanical ventilation.

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 the 6-month immunizations. The parent asks the nurse if the child will receive them. What is the nurse's best response? A. "Your child will receive just the hepatitis immunization today because of the illness." B. "Make an appointment to come back for the immunizations after your child has finished the antibiotics." C. "Your child must be free of infection for 6 months before resuming the immunizations." D. "Your child should have a pneumonia shot today instead."

Correct response: "Make an appointment to come back for the immunizations after your child has finished the antibiotics." Explanation: A common reaction to immunizations is malaise and fever. It is recommended that children who are already moderately to severely ill recover first before receiving any immunization. Once the child is well, normal immunizations can be given. The child does not need to wait 6 months.

During a home visit the nurse observed a mother giving her infant a bath. The nurse documents "Risk for injury (fall) related to parent's knowledge deficit." Which instruction by the nurse best addresses this nursing diagnosis? "Hold the neonate loosely and gently." "Support the neonate's head and back with the forearm." "Use one hand to support the neonate's head." "Strap the neonate into the bath basin."

Correct response: "Support the neonate's head and back with the forearm." Explanation: To maintain a secure grip while bathing the neonate, the nurse should support the neonate's head and back with the forearm. A loose hold may increase the risk of dropping the neonate. The nurse must support the neonate's back and head. Strapping the neonate into the bath basin is inappropriate and confining and precludes optimal physical contact.

After the birth of her first neonate, a mother asks the nurse about the reddened areas at the nape of the neonate's neck. How should the nurse respond? "They're normal and will disappear as the baby's skin thickens." "They're a common congenital abnormality." "They commonly result from a traumatic delivery." "They're caused by a blockage in the apocrine glands."

Correct response: "They're normal and will disappear as the baby's skin thickens." Explanation: Capillary hemangioma (also called a "stork bite") may appear on the neonate's upper eyelids, the bridge of the nose, or the nape of the neck. They result from vascular congestion and will disappear as the skin thickens. They are not associated with congenital abnormalities, traumatic delivery, or blocked apocrine glands.

A premature infant has been placed on a home apnea monitor. The nurse is giving discharge instructions to the parents. The nurse begins teaching by stating A. "Your baby will probably need to be monitored until at least age 1." B. "Using the monitor will help your physician determine the frequency of apneic events and how long monitoring is required." C. "You can only give your baby sponge baths until monitoring is discontinued because it's dangerous to take the monitor off at any time." D. "Remove the monitor at least 3 hours per day to allow the baby a rest period."

Correct response: "Using the monitor will help your physician determine the frequency of apneic events and how long monitoring is required." Explanation: Home apnea monitoring helps the physician determine the frequency of apneic events and how long monitoring is required. Use of home monitoring has been helpful in improving neonatal survival. The average length of monitoring is 6 weeks; only occasionally is it required beyond 1 year. The monitor can be removed for bathing and during times when parent or caregiver is physically present and actively engaged with the care of the infant.

The parents of an infant with myelomeningocele ask the nurse about their child's future mental ability. What is the nurse's best response? A. "About one-third have an intellectual disability, but it is too early to tell about your child." B. "Intellectual disabilities occur in about two-thirds of these children, and you will know soon if this will occur." C. "Your child will probably be of normal intelligence since he demonstrates signs of it now." D. "You will need to talk with the health care provider about that, but you can ask later."

Correct response: A. "About one-third have an intellectual disability, but it is too early to tell about your child." Explanation: Approximately one-third of infants diagnosed with myelomeningocele have an intellectual disability, but the degree of disability is variable and it is difficult to predict intellectual functioning in neonates. The parents are asking for an answer now and should not be told to talk with the HCP later.

A nurse is caring for a full-term neonate who is 24 hours old. Assessment findings include axillary temperature of 96.8° F (36° C), apical heart rate of 188 beats/minute, and respiratory rate of 48 breaths/minute. The mother reports that the neonate is lethargic when she tries to breast-feed and looks "like a rag doll." The mother also has a low-grade fever. Pulse oximetry reveals saturation of 89% on room air, and the neonate has dusky mucous membranes. What are the most appropriate nursing interventions? Select all that apply. A. Encourage the mother to breast-feed because the neonate is becoming dehydrated. B. Observe the neonate carefully, contact the physician, and explain her suspicions of early neonatal sepsis. C. Provide blow-by oxygen and monitor the neonate's respiratory status. D. Keep the neonate in the nursery, monitor vital signs every 2 hours, and inform the physician of the neonate's status when the physician makes routine rounds in the nursery. E. Inform the parents that she wants to monitor the neonate closely.

Correct response: B. Observe the neonate carefully, contact the physician, and explain her suspicions of early neonatal sepsis. C. Provide blow-by oxygen and monitor the neonate's respiratory status. E. Inform the parents that she wants to monitor the neonate closely. Explanation: The neonate's symptoms are consistent with early-onset neonatal sepsis. The oxygen saturation, respiratory rate, and cyanosis (evidenced by dusky mucous membranes) indicate that the neonate needs immediate oxygen support. The nurse should contact the physician immediately and continue to monitor the neonate closely. The tachycardia and tachypnea also indicate that the neonate is compromised and may deteriorate rapidly. Keeping the parents informed at this time is important and supports the mother by acknowledging her concerns. There's no evidence that the cause of the neonate's problem is dehydration. The neonate's condition warrants taking vital signs more often than every 2 hours.

In which parts of the body should the nurse administer an intramuscular injection to a 6-month-old infant? A. between the greater trochanter and the posterior superior iliac spine B. the lateral middle third of the thigh between the greater trochanter and the knee C. between the greater trochanter, the iliac crest, and the anterior superior iliac spine D. two finger breadths below the acromion process on the lateral side of the arm

Correct response: B. the lateral middle third of the thigh between the greater trochanter and the knee Explanation: The appropriate site to give an injection to an infant is the vastus lateralis. The dorsogluteal, ventrogluteal, and deltoid muscles are areas for older children and adults.

A parent asks, "How should I bathe my baby now that he has had surgery for his inguinal hernia?" Which instruction should the nurse give the mother? A. "Clean only his face and diaper area for next 2 weeks." B. "Use sterile sponges to cleanse the inguinal incision until healed." C. "Give him a sponge bath daily for 1 week." D. "Let him take a full tub bath daily."

Correct response: C. "Give him a sponge bath daily for 1 week." Explanation: The incision must be kept as clean and dry as possible. Therefore, daily sponge baths are given for about 1 week postoperatively. The infant can have more than just face and diaper area cleaned following surgery. Because this type of surgery results in a wound that heals through primary intention, the skin will heal and cover the wound in 2 to 3 days. Therefore, it is not necessary to use sterile gauze to cleanse the incision; clean technique is acceptable. Because the incision must be kept as clean and dry, full tub baths are inappropriate.

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 mother that the child may have a developmental delay.

Correct response: Do nothing because this is a normal finding in a child this age. Explanation: An 11-month-old child is expected to cruise but not necessarily walk without support. Use of a walker at home are not recommended because they may tip and increase the risk for falls. A developmental specialist consult is not necessary. Even if the child's development in walking is slow, this fact is not sufficient data to make the nurse suspect developmental delay.

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? A. Assess motor and sensory function of the legs. B. Examine the fontanels and sutures. C. Advise the mother of the need for follow-up in 1 month. D. Obtain a written consent for transillumination.

Correct response: Examine the fontanels and sutures. Explanation: Head circumference usually parallels the percentile for length. The discrepancy found requires close and immediate attention because it could indicate hydrocephalus with its potential for brain damage. Therefore, the nurse should examine the fontanels and sutures. In an infant, bulging fontanels and widening cranial sutures are signs of increasing intracranial pressure related to increased cerebrospinal fluid in the cranial space.Assessing motor and sensory function of the legs would be done if the fontanel or sutures were abnormal.Since the infant requires immediate attention, follow-up in 1 month is inadequate.Transillumination is a noninvasive procedure used to assess hydrocephalus. It does not require a written consent and would be performed after examining the fontanel 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 volume-control chamber I.V. tubing with a macrodrip chamber I.V. tubing with a special filter standard I.V. tubing used for adults

Correct response: I.V. tubing with a volume-control chamber Explanation: Because infants have a small circulating blood volume, inadvertent administration of extra I.V. fluid can cause fluid volume excess. To prevent this from occurring, I.V. tubing with a volume-control chamber should always be used for infants and children to closely regulate the amount of fluid infused. The volume-control chamber should be filled only with enough I.V. fluid for the next two 2 hours. A microdrip chamber that allows for 60 drops/ml (as opposed to a macrodrip chamber, which allows for 10 to 20 drops/ml, depending on the manufacturer) should be used to infuse the smaller amounts of I.V. fluids an infant needs. A filter is typically used only for the administration of total parenteral nutrition and certain blood products. Standard I.V. tubing for adults should be avoided for infants because of the inability to closely regulate the amount of fluid infused.

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's test Galeazzi's sign Ortolani's sign Trendelenburg's sign

Correct response: Ortolani's sign Explanation: Ortolani's sign refers to the "click" made when the femoral head slips forward into the acetabulum when forward pressure is exerted from behind the greater trochanter and the knee is held laterally. This sign indicates hip dislocation.A positive Barlow's test, evidenced by the femoral head slipping out over the acetabulum when pressure is applied then slipping back into place when the pressure is released, indicates that the hip is unstable with increased risk of dislocation. Galeazzi's sign refers to shortening of the affected limb in congenital hip dysplasia. It is elicited by flexing the infant's hips and knees while the infant lies supine. The soles of the feet are placed flat near the buttocks, and the knee heights are assessed for equality.

When developing the teaching plan for the parents of a 12-month-old infant with hypospadias and chordee repair, what information is most important to include? A. Assist the child to become familiar with his dressings so he will leave them alone. B. Encourage the child to ambulate as soon as possible by using a favorite push toy. C. Force fluids to at least 2,500 mL/day by offering his favorite juices. D. Prevent the child from disrupting the catheters by using soft restraints.

Correct response: Prevent the child from disrupting the catheters by using soft restraints. Explanation: The most important consideration for a successful outcome of this surgery is maintenance of the catheters or stents. A 12-month-old infant likes to explore his environment but must be prevented from manipulating his dressings or catheters through the use of soft restraints. Allowing the infant to become familiar with the dressings will not prevent him from pulling at them. After surgery the child is allowed limited activity, possibly while sitting in the parent's lap. A 12-month-old infant may or may not be walking. If he is, most likely he will be clumsy and possibly injure himself. Although increasing fluids is important, 2,500 mL/day is an excessive amount for a 12-month-old. Fluid requirements would be 115 mL/kg.

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? A. Provide extra oxygen by using a ventilator or through manual bagging. B. Insert a suction catheter to the appropriate measured length. C. Insert a few drops of sterile saline solution. D. Put on clean gloves.

Correct response: Provide extra oxygen by using a ventilator or through manual bagging. Explanation: Providing extra oxygen before suctioning is the first step because it helps prevent hypoxemia. Insertion of a suction catheter is performed after preoxygenation. Instilling a few drops of sterile saline solution is no longer part of routine suctioning. ET and tracheal suctioning require sterile technique and sterile gloves, not just clean gloves.

A neonate born at 40 weeks' gestation admitted to the nursery is found to be hypoglycemic. At 4 hours of age, the neonate appears pale and his pulse oximeter is reading 75% on room air. What should the nurse do? Increase the IV rate. Provide supplemental oxygen. Record the finding on the chart and repeat the reading in 30 minutes. Wrap the neonate to increase body temperature.

Correct response: Provide supplemental oxygen. Explanation: Recommended pulse oximetry reading in a full-term neonate is 95% to 100%. The saturation reading of only 75% is an indication that the neonate is not adequately oxygenating in room air. Providing supplemental oxygen will increase the neonate's oxygen saturation. Increasing the IV rate will not improve the oxygen saturation. Documenting the finding and taking no action is not appropriate with a saturation of 75%. Wrapping and increasing the body temperature of the neonate may increase the saturation reading only if it is inaccurate due to cold extremities. Caution must be used because overheating a neonate can be harmful.

A nurse suspects an infant may have a tracheoesophageal fistula or esophageal atresia. What is the most important intervention by the nurse? A. Give oxygen. B. Tell the parents. C. Put the neonate in an isolette or on a radiant warmer. D. Report the suspicion to the health care provider.

Correct response: Report the suspicion to the health care provider. Explanation: The provider needs to be told so that immediate diagnostic tests can be done to determine a definitive diagnosis with surgical correction. Oxygen should be given only after notifying the provider, except in an emergency; a need for oxygen is based on the infant's oxygen saturation levels or arterial blood gas results. It is not the nurse's responsibility to inform the parents of the suspected finding. By the time tracheoesophageal fistula or esophageal atresia is suspected, the neonate would have already been placed in an isolette or a radiant warmer.

After resuming feedings in an infant who has undergone a pyloroplasty, which action would be most appropriate? Keep the head of the bed flat with the infant lying supine. Offer 45 mL of an oral electrolyte solution initially. Place the infant in a prone position after each feeding. Starting feedings with 5 to 10 ml, slowly increasing amounts as tolerated.

Correct response: Starting feedings with 5 to 10 ml, slowly increasing amounts as tolerated. Explanation: The child who has undergone pyloroplasty commonly vomits after the first feeding because peristalsis that has been in the right-to-left direction before repair has not reverted to the normal left-to-right direction. Peristalsis reverses as a result of the tightening of the pyloric sphincter, thus not allowing stomach contents to enter the small intestine. Therefore, small feedings of 5 to 10 mL are given and slowly increased as tolerated. The use of oral electrolyte solutions is unnecessary.Because there is a chance of vomiting, it is advisable to place an infant on its right side, which may help the fluid flow through the pyloric valve by gravity.The child will have an abdominal incision, so a prone position would be uncomfortable.

When the nurse is assessing an infant with suspected inguinal hernia, which finding would be most concerning? A. The inguinal swelling is reddened, and the abdomen is distended. B. The infant is irritable, and a thickened spermatic cord is palpable. C. The inguinal swelling can be reduced, and the infant has a stool in the diaper. D. The infant's diaper is wet with urine, and the abdomen is nontender.

Correct response: The inguinal swelling is reddened, and the abdomen is distended. Explanation: Abdominal distention and a redness of the inguinal swelling are significant findings. Their presence in conjunction with area tenderness and inability to reduce the hernia indicate an incarcerated hernia. An incarcerated hernia can lead to strangulation, necrosis, and gangrene of the bowel. Other findings associated with strangulation include irritability, anorexia, and difficulty in defecation. A strangulated hernia necessitates immediate surgical intervention. The ability to reduce the hernia and normal stooling do not indicate it is incarcerated. Irritability is nonspecific and could be caused by various factors. A palpable, thickened spermatic cord on the affected side is diagnostic of inguinal hernia and would be an expected finding. A wet diaper indicates that urine is being excreted, a finding unrelated to inguinal hernia.

A nurse has received report on her clients and notices that they're of varying ages. To prepare for the shift, the nurse reviews Erik Erikson's five stages of psychosocial development. Place the stages in chronological order from infancy to adolescence. Use all options. 1. Identity versus role confusion 2. Autonomy versus shame and doubt 3. Initiative versus guilt 4. Industry versus inferiority 5. Trust versus mistrust

Correct response: Trust versus mistrust Autonomy versus shame and doubt Initiative versus guilt Industry versus inferiority Identity versus role confusion Explanation: During the first stage of Erikson's trust versus mistrust (birth to age 1), the child develops trust as the primary caregiver meets his needs. autonomy versus shame and doubt (1-3) the child gains control of body functions and becomes increasingly independent. initiative versus guilt (ages 3 to 6), -the child develops a conscience and learns about the world through play. industry versus inferiority (ages 6 to 12), the child enjoys working on projects with others, follows rules, and forms social relationships. As body changes begin to take place identity versus role confusion (ages 12 to 19), -becomes preoccupied with looks, how others view him, meeting peer expectation, and establishing his own identity.

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? A. Give the client an over-the-counter cough-and-cold medicine. B. Have the caregiver make an appointment with the healthcare provider for antibiotics. C. Encourage the caregiver to administer aspirin as needed for fever. D. Use a bulb syringe to suction out the nasal passages.

Correct response: Use a bulb syringe to suction out the nasal passages. Explanation: Children under 2 years of age should not take over-the-counter cough-and cold-medications. The symptoms that the caregiver is describing are for the common cold and antibiotics are not needed. Aspirin is contraindicated in children for the treatment of a fever due to the risk of Reye's syndrome. A bulb syringe to suction out the nasal passages of the client is an appropriate intervention.

A 10-month-old child has cold symptoms. The mother asks how she can clear the infant's nose. What would be the nurse's best recommendation? A. Use a cool air vaporizer with plain water. B. Use saline nose drops and then a bulb syringe. C. Blow into the child's mouth to clear the infant's nose. D. Administer a nonprescription vasoconstrictive nose spray.

Correct response: Use saline nose drops and then a bulb syringe. Explanation: Although a cool air vaporizer may be recommended to humidify the environment, using saline nose drops and then a bulb syringe before meals and at nap and bed times will allow the child to breathe more easily. Saline helps to loosen secretions and keep the mucous membranes moist. The bulb syringe then gently aids in removing the loosened secretions. Blowing into the child's mouth to clear the nose introduces more organisms to the child. A nonprescription vasoconstrictive nasal spray is not recommended for infants because if the spray is used for longer than 3 days a rebound effect with increased inflammation occurs.

A 14-month-old child has a severe diaper rash. Which recommendation should the nurse provide to the parents? Continue to use the baby wipes. Change the diaper every 4 to 6 hours. Wash the buttocks using mild soap. Apply powder to the diaper area.

Correct response: Wash the buttocks using mild soap. Explanation: Because the toddler has a severe diaper rash, it may be best to change all that the parents are doing. The buttocks need to be washed thoroughly with mild soap and dried well. In fact, it is helpful to leave the diaper off and expose the buttocks to the air. Baby wipes commonly contain additives and perfumes that may be irritating to the baby's sensitive skin. The diaper needs to be changed more often than every 4 to 6 hours. Otherwise, the moist diaper environment will continue to irritate the skin, causing the rash to worsen. Powder has limited absorbing ability and will most likely irritate the area more. In addition, some powders contain perfumes or are scented and can irritate the skin.

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. a 3-cm increase in abdominal circumference B. periods of occasional fussiness C. absence of bowel sounds since surgery D. bright red stoma

Correct response: a 3-cm increase in abdominal circumference Explanation: Abdominal circumference is measured to monitor for abdominal distention. An increase of 3 cm in 8 hours would require notification of the HCP; it would indicate a substantial degree of abdominal distention, possibly from fluid or gas accumulation. Normally, after surgery, an infant experiences occasional periods of fussiness. However, as long as the infant is able to be quiet by himself or with the aid of a pacifier, the HCP does not need to be contacted. Absence of bowel sounds would be expected after surgery because of the effects of anesthesia. It takes approximately 48 hours for gastric motility to resume. New stomas are typically bright red or pink.

The nurse is providing postoperative care for an infant who had a ventriculoperitoneal shunt placed to correct hydrocephalus. Which clinical finding warrants immediate intervention? abdominal distension lethargy facial edema headache

Correct response: abdominal distension Explanation: Abdominal distension in a pediatric client with a ventriculoperitoneal shunt can be an indication of peritonitis and requires intervention. Lethargy may be present for several days following surgery for a ventriculoperitoneal shunt. Facial and eye edema is common during the postoperative period and can be reduced by utilizing a cold compress to the eyes. Infants commonly have pain in the postoperative period that should be treated with analgesics; however, infants cannot convey that they specifically have a headache.

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? A. contamination of the factor VIII replacement received during bleeding episodes B. casual contact with a child testing positive for human immunodeficiency virus C. use of a contaminated needle to obtain a blood sample for type and crossmatching D. exposure in the waiting room to children with AIDS attending the same hematology clinic

Correct response: contamination of the factor VIII replacement received during bleeding episodes Explanation: The acquired immune deficiency syndrome (AIDS) virus is spread by direct contact with blood or blood products and by sexual contact. Children with hemophilia were at risk for AIDS in the 1980s because the factor VIII concentrate infusions were made from pooled plasma. However, factor VIII is now a recombinant synthesized factor product, which virtually eliminates the risk of contacting HIV with an infusion.There is no evidence that casual contact between infected and uninfected people transmits the human immunodeficiency virus (HIV). Exposure to others in a waiting room is considered casual contact.All venipunctures for blood specimens in hospitals and clinics are performed with sterile disposable needles. Because the needles are sterile, they cannot be a source of HIV transmission.

The nurse provides a neonate with an initial feeding. The nurse would suspect a tracheoesophageal fistula if the neonate demonstrated which behavior? A. sucking attempts that are too poorly coordinated to be effective B. projectile vomiting that occurs after drinking 4 oz (120 mL) C. coughing, choking, and cyanosis that occur after several swallows of formula D. sleeping that occurs after taking 10 mL of formula

Correct response: coughing, choking, and cyanosis that occur after several swallows of formula Explanation: The newborn with tracheoesophageal fistula swallows normally, but the fluids quickly fill the blind pouch. The infant then coughs, chokes, and becomes cyanotic while the fluid returns through the nose and mouth.Poor rooting reflexes and sucking attempts are typical of infants with neurologic dysfunction or related to reflex depression secondary to medication given to the mother during labor.Projectile vomiting is typical of infants with neurologic dysfunctions.This reflex may also be depressed by medication given to the mother during labor. Falling asleep after taking little formula is characteristic of an infant who becomes exhausted with the exertion of feeding, commonly caused by a cardiac anomaly.

The mother 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 after 6 months of age at 1 year of age

Correct response: during the first 6 months of life Explanation: Cleft lips are typically repaired during the first 6 months of life. This allows the child to form a better seal around the nipple of a bottle for feeding and strengthens muscles needed for speech. If the surgery is delayed until after 6 months, the child may have possible dental issues and problems with sucking. The repair is not done at birth because the infant must first gain weight to safely undergo surgery. The palate should be closed by 18 months to protect the formation of tooth buds and allow the infant to develop more normal speech patterns.

The nurse teaches the parents of a neonate who has undergone corrective surgery for tracheoesophageal fistula about the need for long-term health care. The nurse bases the teaching on the child's high risk for which condition? speech problems esophageal stricture gastric ulcers recurrent mild diarrhea with dehydration

Correct response: esophageal stricture Explanation: After corrective surgery for repair of tracheoesophageal fistula (TEF), the risk for esophageal stricture is high because scar tissue forms at the site of the esophageal anastomosis, commonly requiring dilation at the anastomosis site during the first years of childhood in about half of such children.Speech problems are likely if other abnormalities are present to produce them. However, the larynx and structures of speech are not affected by TEF.Although dysphagia and strictures may decrease food intake and poor weight gain may result, gastric ulcers are not associated with TEF repair.Recurrent mild diarrhea with dehydration typically does not develop from surgery to correct TEF.

A child with cystic fibrosis has been admitted to the pediatric unit. What type of diet should the nurse request for the client? high-fat, high-carbohydrate high-calorie, high-protein high-calorie, high-carbohydrate high-carbohydrate, high-protein

Correct response: high-calorie, high-protein Explanation: A high-calorie, high-protein diet is necessary to ensure adequate growth. Some children require up to two times the recommended daily allowance of calories (increased calorie diet includes foods high in fat and balanced carbohydrates). Pancreatic enzyme activity is lost and malabsorption of fats, proteins, and carbohydrates occurs.

An infant admitted to the hospital with an acute rotavirus infection is having frequent diarrheal stools. On assessment, the nurse notes 40 to 60 bowel sounds per minute. The child has poor skin turgor and dry mucous membranes. The nurse determines the infant's dehydration is related to which factor? decreased gastric emptying insufficient antidiuretic hormone inability to metabolize nutrients increased GI motility

Correct response: increased GI motility Explanation: Rotavirus is a type of viral infection that affects the GI tract. It causes diarrhea, which results in fluid loss. This type of infection can be very serious in infants who, because of their immature kidneys, cannot adjust to fluid loss as readily as adults.Acute diarrheal infection results in increased gastric emptying.Insufficient production of antidiuretic hormone is not a consequence of acute diarrheal infection.Acute diarrheal infection results in malabsorption, not an inability to metabolize nutrients that are absorbed.

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? 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

Correct response: intermittent with knees drawn to the chest 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. Feeding does not precipitate episodes of pain. Additionally, a 4-month-old infant typically would not be ingesting solid foods. Pain exhibited by crying that occurs when the infant is placed in a reclining position, as in the mother's arms, is not associated with intussusception. This type of cry may indicate that the infant wants attention, wants to be held, or needs to have a diaper change.

The emergency department nurse has admitted an infant with bulging fontanels, setting sun eyes, and lethargy. Which diagnostic procedure would be contraindicated in this infant? lumbar puncture magnetic resonance imaging arterial blood draw computerized tomography scan

Correct response: lumbar puncture Explanation: The child is exhibiting signs and symptoms of increased intracranial pressure (ICP). A lumbar puncture is contraindicated in children with increased ICP due to the risk of herniation. Magnetic resonance imaging and a computerized tomography scan are indicated in children with suspected increased ICP. Radiology studies will allow visualization of the cause of the increased ICP, such as inflammation, a tumor, or hemorrhage. An arterial blood draw is not indicated in this client. However, there is no contraindication for performing an arterial blood draw on a child with increased ICP.

The nurse is treating an 8-month-old infant with scabies. What medication would the nurse prepare to administer for this infant? A. griseofulvin B. tolnaftate C. thiabendazole D. permethrin

Correct response: permethrin Explanation: Permethrin, supplied in a cream, is the treatment of choice for children younger than age 1. However, its safety hasn't been established for clients younger than 2 months. Griseofulvin and tolnaftate are used to treat ringworm, not scabies. Thiabendazole is used to treat hookworm, roundworm, threadworm, and whipworm.

A nurse should assess the maturity of enzyme systems (kidney and liver) in which pediatric population before administering medications? adolescents neonates premature infants toddlers

Correct response: premature infants Explanation: Factors related to growth and maturation significantly alter an individual's capacity to metabolize and excrete drugs. Thus, the premature infant is at risk for problems because of immaturity. Deficiencies associated with immaturity become more important with decreasing age. Enzyme systems develop quickly, with most increasing to adult levels within 1 to 8 weeks after birth. Within the first year of life, all are probably as active as they will ever be.

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? A. policies from other hospitals B. data from retrospective studies C. published national standards D. expert opinions

Correct response: published national standards Explanation: Published national standards are based on the best evidence and when available should serve as the foundation for nursing unit policies. Policies from other hospitals may or may not be evidence based. Retrospective studies and expert opinions should only be used to form policy when data from experimental studies or national standards are not available.

During an assessment of a 10-month-old infant, you note on the infant's gum line two teeth that have erupted. These are the only teeth present in the infant's mouth. These teeth are known as the? A. Lower central incisors B. Upper central incisors C. Lateral incisors D. Canine

A. Lower central incisors The lower central incisors are the first teeth that erupt in an infant's mouth and this tends to occur by 10 months of age.

2. An infant weighed 8 lbs. at birth. How many lbs. should the infant weigh at 6 months?* A. 24 lbs B. 10 lbs C. 16 lbs D. 32 lbs

C. 16 lbs Explaination: 6 months --> wt doubles1 year --> wt triplesExample: 8 lbs. at birth......16 lbs. at 6 months....24 lbs. at 1 year

In developing a security plan for a pediatric unit, a nurse must consider which factors? Select all that apply. A. identification of neonates, infants, toddlers, children, and adolescents at all times B. the facility's physical layout C. the climate in which the hospital is located D. available resources to obtain and maintain the security plan E. methods for educating all staff regarding the security plan

A. identification of neonates, infants, toddlers, children, and adolescents at all times B. the facility's physical layout D. available resources to obtain and maintain the security plan E. methods for educating all staff regarding the security plan Explanation: When developing a security plan for a pediatric unit, the nurse should consider the identification of neonates, infants, toddlers, children, and adolescents; the facility's physical layout; available resources; and methods for educating staff. The nurse does not need to consider the climate in which the hospital is located.

An infant was 21 inches at birth. How many inches should the infant be at 6 months?* A. 30-36 inches B. 24-27 inches C. 23-25 inches D. 22-24 inches

B. 24-27 inches Explanation: growth 0.5 - 1 inch Q month until 6 months Example: 21 inches at birth......24-27 inches at 6 months

At what age would you educate the parents of an infant to stop swaddling the infant because the infant will be able to roll over onto its tummy? A. 2 months B. 4 months C. 6 months D. 10 months

B. 4 months An infant should not be swaddled once they can roll over, which is about 4 months.

You're assessing a 10-month-old infant. You note on examination the anterior fontanelle is open. The nurse will:* A. Document this as an abnormal finding because this fontanelle should close at 2 months B. Document this as a normal finding because this fontanelle closes at about 18 months C. Document this as a normal finding because this fontanelle closes at about 12 months D. Document this as an abnormal finding because this fontanelle should close at 6 months

B. Document this as a normal finding because this fontanelle closes at about 18 months Explaination: Anterior closed by 18 months Posterior closed by 2 months

7. At 8-9 months of age, what milestone should an infant be able to successfully perform? A. Begin walking B. Say several words like mama or dada C. Sit without support D. Follow basic commands

C. Sit without support Explanation: -Infants begin walking, saying simple words, following simple commands at 10-12 months.

You're assessing a 2-month-old infant. Which finding below is a normal milestone that should be reached by this infant at this age?* A. The infant can sit up with support. B. The infant holds a rattle. C. The infant smiles at its parent. D. The infant is afraid of strangers.

C. The infant smiles at its parent. Explanation: By 2 months of age the infant should be able to smile at parent. Age 6 months is when an infant can sit up without support. Holding a rattle would not occur until 8-9 months when the baby starts to develop pincer grasp. By 6 months, stranger anxiety begins.

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? A. No action is needed; this is a normal finding. B. Inform the physician of the finding and obtain an order for a chest X-ray. C. Instruct the parents to bring the infant back in 1 month for reevaluation. D. Check the infant for signs of respiratory distress.

Correct response: No action is needed; this is a normal finding. Explanation: No action is needed by the nurse because in an infant, the anteroposterior diameter is normally equal that of the lateral diameter (a ratio of 1:1). As the infant reaches toddlerhood, the anteroposterior diameter becomes less than the lateral diameter.

A 15-month-old child is recovering from surgery, and the nurse is performing a postoperative pain assessment. The nurse documents what findings as evidence of pain? Select all that apply. A. crying B. increasing heart rate C. rating pain as 8/10 D. throwing toys E. touching the wound dressing

Correct response: A. crying B. increasing heart rate E touching the wound dressing Explanation: A behavioral change is one of the most valuable clues to pain. A child who is pain-free likes to play. A child of this age will not use a numeric rating scale for pain. It is typical for a child of this age to throw toys, and engagement in play is not a sign of pain. An increased heart rate may indicate increased pain. Touching the area is also an indicator that there is pain.

. What other congenital heart defect is most commonly present in truncus arteriosus?* A. Atrial septal defect B. Pulmonary stenosis C. Tetralogy of Fallot D. Ventricular septal defect

D. Ventricular septal defect A ventricular septal defect (VSD) is commonly present in this CHD. The VSD will be near the truncus arteriosus and it will allow blood to mix in the right and left ventricles and enter the truncus artery. It is very uncommon for one not to be present.

As the nurse you know that some patients who have coarctation of the aorta will develop collateral circulation of the arteries due to the abnormality on the aorta. Which option below indicates a patient is experiencing collateral circulation?* A. Chest x-ray that demonstrates notching on the ribs B. A harsh diastolic murmur on inspiration at the 2nd intercostal border C. Ejection fraction of 12% on an echocardiogram D. Chest x-ray that demonstrates cardiomegaly

The answer is A. Notching of the ribs is due to collateral circulation in CoA. The body creates extra circulation to bypass the narrowing, which will be seen on the ribs and cause them to have a notched out appearance on a chest x-ray.

You're educating a group of parents about car seat safety. A participant asks about the best position of a car seat for a 6-month-old. Your response is: A. Forward-facing and back seat B. Forward-facing and front seat C. Rear-facing and front seat D. Rear-facing and back seat

This answer is D: Rear-facing and back seat

You're performing a head-to-toe- assessment on a newborn with severe coarctation of the aorta. You note a systolic heart murmur. Where is this heart murmur best auscultated in a patient with this condition?* A. at the 4th intercostal space left to the sternal border B. at the left interscapular area C. at the 2nd intercostal space right to the sternal border D. at the mid-subclavicular line right of the sternal border

The answer is B. The type of heart murmur generally present in CoA is a systolic murmur. It is best heard in the interscapular area on the left (which is the back near the shoulder blade).

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

Correct response: Babinski Explanation: The nurse should be able to elicit the Babinski reflex because it may be present the entire first year of life. The startle reflex actually disappears around 4 months of age; the Moro reflex, by 3 or 4 months of age; and the dance reflex, after the third or fourth week.

You're teaching a class to a group of parents about congenital heart defects. During the class discussion, you ask the group to describe the surgical repair for truncus arteriosus. Select all the TRUE statements by the group members about this surgical repair:* A. "During the surgery the pulmonary arteries are separated from the truncus arteriosus and connected to the right ventricle using a valved conduit." B. "This surgery is done within the first 2-3 months of life." C. "Some patients may need another surgical repair later on because of narrowing of the conduit that may occur or they may outgrow it." D. "During the surgery the aorta is separated from the truncus arteriosus and connected to the left ventricle using a valved conduit."

A. "During the surgery the pulmonary arteries are separated from the truncus arteriosus and connected to the right ventricle using a valved conduit." C. "Some patients may need another surgical repair later on because of narrowing of the conduit that may occur or they may outgrow it." These are the only correct statements. Option B is WRONG because this surgery is performed with the first 2 weeks of life. Option D is wrong because during the surgery the pulmonary arteries are separated from the truncus arteriosus and connected to the right ventricle using a valved conduit.

Which of the following genetic disorders increases a patient risk of developing truncus arteriosus? A. Edward's syndrome (trisomy 18) B. Down syndrome C. DiGeorge syndrome D. Patau syndrome

C. DiGeorge syndrome About 33% of babies with truncus arteriosus have a genetic problem called DiGeorge syndrome (C.S. Mott Children's Hospital).

The parents of an infant with myelomeningocele ask the nurse about their child's future mental ability. What is the nurse's best response? A. "About one-third have an intellectual disability, but it is too early to tell about your child." B. "Intellectual disabilities occur in about two-thirds of these children, and you will know soon if this will occur." C. "Your child will probably be of normal intelligence since he demonstrates signs of it now." D. "You will need to talk with the health care provider about that, but you can ask later."

Correct response: "About one-third have an intellectual disability, but it is too early to tell about your child." Explanation: Approximately one-third of infants diagnosed with myelomeningocele have an intellectual disability, but the degree of disability is variable and it is difficult to predict intellectual functioning in neonates. The parents are asking for an answer now and should not be told to talk with the HCP later.

Which toxic adverse reaction should the nurse monitor in a toddler taking digoxin? weight gain tachycardia nausea and vomiting seizures

Correct response: nausea and vomiting Explanation: Digoxin toxicity in infants and children may present with nausea, vomiting, anorexia, or a slow, irregular heart rate. Weight gain, tachycardia, and seizures are not findings in digoxin toxicity.

. A 6.5-month-old is hospitalized. What nursing intervention will you include in their plan of care?* A. Separate the infant and parent during procedures B. Maintain the infant's daily rituals and routines C. Allow the infant to examine equipment before usage D. Maintain the same nursing staff during each shift

D. Maintain the same nursing staff during each shift At this age, stranger anxiety begins to develop. Therefore (if possible), the same nursing staff should be used for providing care. Option A would increase anxiety in the infant and options C and B are for older children.

Your patient is 5-months-old. Which developmental milestone, if not performed by the infant, should be further investigated? A. Crawling B. Rolling over from back to tummy C. Using the pincer grasp D. Sitting without support

The answer is B. A 5-month-old should be able to roll over from its back to tummy. The other options are milestones for older infants.

After the birth of a newborn with severe coarctation of the aorta, the physician orders a prostaglandin infusion. As the nurse you know that this medication will have what type of therapeutic effects? Select all that apply: A. Prevent the foramen ovale from closing B. Allow a connection between the aorta and pulmonary artery C. Decrease the workload on the left ventricle D. Increase blood flow to the lower extremities

The answers are B, C, and D. If CoA is severe in a newborn, they may be started on a prostaglandin infusion to keep the ductus arteriosus open (allows a connection between the pulmonary artery and aorta), which will help decrease the work load on the left ventricle and help blood to flow to the lower extremities.

An infant is to have moderate sedation for an outpatient procedure. The nurse knows that A. the infant should respond to gentle tactile or verbal stimulation. B. the infant's reflexes will be decreased or absent. C. the infant will remember the procedure. D. the infant will need a patient-controlled analgesia (PCA) pump during sedation.

Correct response: the infant should respond to gentle tactile or verbal stimulation. Explanation: An infant under moderate sedation should respond to verbal or tactile stimuli. Infants under general anesthesia have decreased or absent reflexes. Infants who undergo general or moderate sedation rarely remember the procedure. PCA pumps aren't used during sedation.

A neonate receives an IV infusion of dextrose 10% administered by an infusion pump. The nurse should verify the alarm settings on the infusion pump at which times? Select all that apply. when the infusion is started at the beginning of each shift when the neonate returns from X-ray when the neonate moves in the crib after the parents have visited

Correct response: when the infusion is started at the beginning of each shift when the neonate returns from X-ray Explanation: The alarm settings on infusion pumps should be verified at the time the infusion is started, at the beginning of each shift, and when the client is moved. The neonate can move in bed, but if the alarm is triggered, the nurse should verify the settings. Unless the neonate has moved or been taken out of the crib, it is not necessary to check alarm settings after the parents visit.

The nurse should refer the parents of an 8-month-old child to a health care provider (HCP) if the child is unable to demonstrate which gross motor ability? A. stand momentarily without holding onto furniture B. stand alone well for long periods of time C. stoop to recover an object on the ground D. sit without support for long periods of time

Correct response: sit without support for long periods of time Explanation: According to the Denver Developmental Screening Examination, a child of 8 months should sit without support for long periods of time. An 8-month-old child does not have the ability to stand without hanging onto a stationary object for support. His muscles are not developed enough to support all his weight without assistance. His balance has not developed to the point that he can stand and stoop over to reach an object.

You're providing discharge education to the parents of a child who just had surgery to repair coarctation of the aorta. What should the nurse include in the teaching about issues that can arise after surgery that must be closely monitored by a cardiologist? Select all that apply: A. Dilation of the aorta B. Restenosis of the aorta C. Hyperglycemia D. Hypertension

The answers are B and D. After repair of the aorta, there is always the chance the aorta can narrow again (restenosis) and that the child continues to have hypertension that must be treated with medication. The cardiologist will need to monitor the patient for this long-term.

Your patient is 6-months-old. According to Erickson's Stage of Development, this patient is in what stage? A. Autonomy vs. Shame & Doubt B. Trust vs. Mistrust C. Initiative vs. Guilt D. Identity vs. Role Confusion

The answer is B: Trust vs. Mistrust in this stage from 0-18 months

A newborn is taking Digoxin prior to surgical repair of a truncus arteriosus. You're assessing morning labs and the patient's Digoxin level is 1.8 ng/mL. The next dose of Digoxin is due at 1000. As the nurse you will? Select all that apply:* A. Redraw a Digoxin level to confirm the morning lab level B. Hold the 1000 dose and notify the physician C. Administer the dose as ordered D. Administer the dose as ordered, but notify the physician about the abnormal level E. Check apical pulse prior to administration of the scheduled dose at 1000 F. Hold scheduled dose if apical pulse less than 60

C. Administer the dose as ordered E. Check apical pulse prior to administration of the scheduled dose at 1000 F. Hold scheduled dose if apical pulse less than 60 A normal digoxin level is 0.5-2 ng/mL (the patient's digoxin level is normal in this scenario). Therefore, the nurse should ADMINISTER the dose as ordered.....AFTER checking the apical pulse. The nurse would hold the dose if the apical pulse was less than 90-110 beats per minute in an INFANT. It is less than 60 bpm for adults (that is why option F is wrong).

You're providing care to a 1-month-old infant who is hospitalized. The parents are unable to be at the bedside. The infant is crying. Select appropriate nursing interventions for this infant: A. Let the infant play with crib mobiles B. Swaddle the infant C. Attempt to play peek-a-boo with the infant D. Rock the infant E. Distract the infant with a toy

The answers are B and D. An infant this age should have their needs responded to promptly. Appropriate interventions would be swaddling and rocking the infant. The other nursing interventions listed are more appropriate for an older infant. This infant is very young.

You note a 10-month-old is using the pincer grasp. Which option below best describes this milestone? A. The infant is able to grasp large objects with the palm and forefingers. B. The infant is able to grasp small objects with the index finger and thumb. C. The infant is able to grasp small and large objects with the middle finger and thumb. D. The infant is able to grasp large objects with the palm and thumb.

The answer is B. The infant is able to grasp small objects with the index finger and thumb.

You're developing a plan of care for an infant and you include activities for play. The play activities include hiding a toy and letting the infant look for it along with playing peek-a-boo. Which infant below would best benefit from this type of play? A. 6-month-old B. 2-month-old C. 9-month-old D. 4-month-old

The answer is C: 9-month-old. Infants at this age understand object permanence. This is when an object can be hidden and the infant understands it still exists. This happens around 8-9 months.

You're helping develop a meal plan for a 10-month-old. Which foods will you select to be part of the meal plan? Select all that apply: A. Mashed potatoes B. Grapes C. Soup D. Toast with honey

The answers are A and C. Option B should be avoided because it's a choking hazard, and option D is wrong because infants under 12 months should not have honey.

A newborn has severe coarctation of the aorta. What signs and symptoms would you expect to find in this patient? Select all that apply:* A. Very strong bounding pulses in the upper extremities B. Cool legs and feet C. Machine-like murmur only on systole D. Tet spells with activity E. Severe cyanosis F. Absent/diminished femoral pulses

The answers are: A, B, and F. These are all signs and symptoms present in CoA.

The nurse is assessing a 10-month-old infant during a checkup. Which developmental milestones would the nurse expect the infant to display? Select all that apply. A. holding head erect B. self-feeding with a spoon C. demonstrating good bowel and bladder control D. sitting on a firm surface without support D. bearing majority of weight on legs E. walking alone

Correct response: A. holding head erect D. sitting on a firm surface without support D. bearing majority of weight on legs Explanation: By age 4 months, an infant would be able to hold the head erect. By age 9 months, the infant would be able to sit on a firm surface without support and bear the majority of weight on the legs (for example, walking while holding onto furniture). Self-feeding and bowel and bladder control are developmental milestones of toddlers. By age 12 months, the infant would be able to stand alone and may take the first steps.

Which action should a nurse include in the care plan for a 2-month-old infant with heart failure? Allow the infant to rest before feeding. Bathe the infant and administer medications before feeding. Weigh and bathe the infant before feeding. Feed the infant when the infant cries.

Correct response: Allow the infant to rest before feeding. Explanation: Because feeding requires so much energy, an infant with heart failure should rest before feeding. Bathing and weighing the infant and administering medications should be scheduled around feedings. An infant expends energy when crying; therefore, it's best if the infant doesn't cry.

The nurse is to administer IV fluids to an infant. Which safeguard would be most important for the nurse to use? A. Administration of fluid at the slowest possible rate by infant weight B. Use of a gravity infusion set C. Use of a micro drop (mini drip) infusion set D. Use of an infusion pump to regulate the flow rate

Correct response: Use of an infusion pump to regulate the flow rate Explanation: Use of an infusion pump to regulate the flow rate is the appropriate safeguard, because infants and children are particularly vulnerable to I.V. fluid overload. Administering fluid at the slowest possible rate may not benefit the infant. Using a gravity infusion set or a micro drop infusion set will not protect against fluid overload when I.V. administration is too rapid.

Select all the true statements about the aorta:* A. "The ascending aorta branches off to supply the coronary arteries of the heart." B. "It's the third largest artery in the body." C. "The aorta comes off the right ventricle and supplies oxygenated blood to the body." D. "The aortic arch branches off to supply the head, neck, and upper extremities."

The answers are A and D. These statements are true about the aorta. Option B is wrong because the aorta is the LARGEST artery in the body (not the third largest). Option C is wrong because the aorta comes off the LEFT (not right) ventricle.

A 12-month-old arrives to the health clinic for a well visit. You're assessing the infant's developmental milestones. Select below all the milestones the child should be able to perform? A. Rides a tricycle B. Draws a triangle C. Pulls to a standing position and can take a few steps D. Follows simple commands like "wave bye-bye" E. Puts objects in a container F. Hits two small wooden blocks together G. Says 2-3 word sentences

The answers are: C, D, E, F. The other options are milestones for older children.

A 3-week-old infant is exclusively breast fed. What will you include in the patient education to the mother during this clinic visit? A. Introduce solid foods around 3-4 months of age along with breast feeding. B. The infant needs to be supplemented with Vitamin D (400 IU) daily. C. Cow's milk may be substituted for breast milk around 6 months. D. Breast feeding is only recommended for the first 4 months of life.

The answer is B. Infants that are exclusively (ONLY) breast fed should receive Vitamin D supplementation (400 IU) daily per AAP guidelines.

Which assessment would be the most important for the nurse to include in the plan of care for an infant experiencing severe diarrhea? A. monitoring the total 8-hour formula intake B. weighing the infant each day C. checking the anterior fontanel every shift D. monitoring abdominal skin turgor every shift

Correct response: weighing the infant each day Explanation: Because an infant experiencing severe diarrhea is at high risk for a fluid volume deficiency, the nurse needs to evaluate the infant's fluid balance status by weighing the infant at least every day. Body weight is the best indicator of hydration status because a higher proportion of an infant's body weight is water, compared with an adult. Initially, the infant with severe diarrhea is not allowed liquids but is given fluids intravenously. Therefore, monitoring the oral intake of formula is inappropriate. Although checking the anterior fontanel for depression or bulging provides information about hydration status, this method is not considered the best indicator of the infant's fluid balance. Monitoring skin turgor can provide information about fluid volume status. The abdomen is commonly used to assess skin turgor in an infant because it is a large surface area and can be accessed quickly. However, weight is the best indicator of fluid balance.

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? 3 months 6 months 8 months 10 months

Correct response: 6 months Explanation: Solids should be introduced at 6 months. Full-term infants use up their prenatal iron stores within 4 to 6 months after birth. Milk contains insufficient iron.

You're caring for a child with coarctation of the aorta and educating the parents about the child's condition. Which statement by the parents demonstrates they understood the pathophysiology of this defect?* A. "This condition can lead to right-sided heart failure." B. "The narrowing of the aorta leads to a high blood pressure in the arteries that are found before the site of narrowing in the aorta." C. "The dilation of the aorta leads to a decrease blood pressure in the arteries that are found after the site of dilation." D. "The upper and lower extremities will experience a decrease in blood flow due to the defect in the aorta."

The answer is B. This is the only correct statement about CoA. Option A is wrong because this condition leads to LEFT side heart failure (not right side). Option C is wrong because this condition is due to NARROWING (not dilation) of the aorta. Option D is wrong because ONLY the lower extremities (not upper) will experience a decrease in blood flow.

A parent brings her 3-month-old child into the emergency department. The child is listless with dry mucous membranes, tenting of the skin on the forehead, a depressed fontanel, and a history of vomiting and diarrhea for the last 36 hours. In what order from first to last should the nurse implement the primary care provider's prescriptions? All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1. Insert an IV and infuse fluids as prescribed. 2. Obtain vital signs and weight. 3. Apply a urine collection bag. 4. Draw blood for laboratory tests.

Correct response: 2. Obtain vital signs and weight. 3. Apply a urine collection bag. 1. Insert an IV and infuse fluids as prescribed. 4. Draw blood for laboratory tests. Explanation: The nurse should first obtain vital signs and evaluate the child for signs of shock or cardiac arrhythmias. The weight can also be obtained at this time to estimate the amount of fluid lost. The nurse should next apply the urine collection bag. As soon as possible after these steps, the nurse should insert an IV to replace lost fluids, electrolytes, and sugar to reduce the incidence of metabolic acidosis created by the lack of calorie intake and the loss of electrolytes. Blood should be drawn to assess the severity of electrolyte imbalance and other possible causes for the diarrhea and vomiting.

You're teaching a new mom of a 1-week-old infant on how to prevent SIDS (Sudden Infant Death Syndrome). Which statement by the parent requires you to re-educate the parent on this topic? A. "The best sleeping position for the baby is on their side or tummy". B. "It's okay to share the same room with the baby." C. "I will stop swaddling the baby once he can roll over onto his tummy". D. "I will be sure to remove extra blankets and toys from the baby's bed."

The answer is A. The best sleeping position for the baby is on their BACK....NOT side or tummy.

A newborn is diagnosed with truncus arteriosus. You're educating the parents about this heart defect. Which statement by the mother demonstrates she understood the education provided about this condition A. "My baby has narrowing in the pulmonary artery, and the aorta is arising out of the right ventricle rather than the left ventricle." B. "My baby's heart shares one artery that connects the right and left ventricles." C. "The left side of my baby's heart is not fully developed." D. "The natural structure in my baby's heart, the ductus arteriosus, has failed to close after birth leading to more blood flow to the lungs."

The answer is B. Truncus arteriosus is a congenital heart defect where there is ONE artery along with one truncal valve that connects the right and left ventricles. This structure will function to carry blood to both the lungs and body. In a normal heart, there should be TWO separate arteries (pulmonary artery and aorta) with their own valves (instead of one truncal valve). The pulmonary artery will carry blood from the right side of the heart to the lungs, and the aorta will carry blood from the left side of the heart to the body.

A 1-day-old infant is ordered an echocardiogram due to abnormal signs and symptoms related to a congenital heart defect. The echo confirms that truncus arteriosus is present. What signs and symptoms may present in this congenital heart defect? Select all that apply: A. Cyanosis B. Machinery-like murmur C. Poor feeding D. Inability to gain weight E. Hypercyanotic spells F. Clubbing of fingers

A. Cyanosis C. Poor feeding D. Inability to gain weight Deoxygenated blood is going to the body, while more blood is shifting to pulmonary circulation via a shared artery. This leads to cyanosis (bluish body at birth) and dyspnea. Heart failure and pulmonary hypertension occur within the first weeks of life. The baby can experience poor feeding and poor weight gain, low cardiac output, activity intolerance, sweating that is cold and calmly, nutrition issues, crackles in lungs etc. A heart murmur from the blood flowing through the truncus arteriosus can create a turbulence leading to an ejection systolic murmur heard at the left sternal border. A machinery-like murmur is present in patent ductus arteriosus, and hypercyanotic spells are present in tetralogy of fallot (also called tet spells).

. A 3-day-old infant is diagnosed with truncus arteriosus. As the nurse, you know to monitor the infant for what complications? Select all that apply A. Tet spells B. Heart failure C. Pulmonary hypertension D. Increased cardiac output

B. Heart failure C. Pulmonary hypertension This infant has only one artery that is arising out of the right and left ventricle. Deoxygenated and oxygenated blood is mixing in the ventricles, entering the truncus arteriosus, and going to both the lungs and systemic circulation. Consequently, more blood is flowing to the lungs than the systemic circulation (the body) because resistance in lower to the lungs than the body. Hence, it is easier to pump blood to the lungs than to body (blood flow to the body requires a lot of pressure when compared to the lungs). It's important to note that the blood that is entering the body is a mixture of deoxygenated and oxygenated blood (leading to cyanosis). Now because there is more blood flow going to the lungs, this leads to damage to the arteries that feed the lungs, and this leads to pulmonary hypertension. The pulmonary hypertension increases the resistance the heart must pump against to get the blood to the lungs. Therefore, the heart becomes very weak from having to pump so hard against the resistance to the lungs, and this leads to heart failure. Many infants with a severe case of truncus arteriosus will develop heart failure within the first 7 days of life. Tet spells are found in the congenital heart defect tetralogy of fallot, and there is DECREASED cardiac output with this condition (not increased).

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? A. becoming dark brown in 2 months B. staying deep red in color C. changing to several shades of pink D. turning almost purple in color

Correct response: staying deep red in color Explanation: Typically, the stoma should remain deep red in color as long as the infant has the colostomy. A dark red to purplish color may indicate impaired circulation to the stoma.

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.

Correct response: the inside of the infant's mouth. Explanation: The nurse should pay close attention to the inside of the infant's mouth for white patches. Signs of thrush, these patches are common in children with C. albicans infections and should be reported to the physician. Although the other assessments should be performed as a part of an infant evaluation, they aren't the nurse's primary focus in this situation.