Pediatric/Child Health Nursing - Infants - Exam 1

Electrocardiography is scheduled for an infant who has tetralogy of Fallot. The mother asks the nurse what type of test this is and why it is done. Which is the best response by the nurse?

"Electrical activity in the baby's heart is recorded, then printed on graph paper."

Which parental statement would the nurse recognize as a knowledge deficit when discussing care of an infant with a severe diaper rash?

"I direct a heat lamp at the buttocks."

The nurse knows that additional discharge instructions are needed for parents whose infant has just undergone corrective surgery for cleft palate when the parent makes which statement?

"Lying on the abdomen is prohibited, so we'll keep him in an infant seat."

The parent of a newborn asks a nurse why, except for hepatitis B vaccine, the immunization schedule does not start until the infant is 2 months old. Which response would the nurse provide?

"Maternal antibodies interfere with the development of active antibodies by the infant when immunized."

Because of a measles epidemic, a 6-month-old infant receives measles immunoglobulin. Which education would the nurse provide the parents about the recommended age for vaccination to ensure continuous protection against measles?

12 months

An infant with persistent diarrhea is subject to significant fluid and electrolyte alterations. Which physiologic imbalances would the nurse most likely encounter?

-Hypovolemia -metabolic acidosis

How is the Apgar score calculated?

-calculated from scores in five areas: heart rate, respiratory effort, muscle tone, reflex irritability, and color -pulse over 100 = 2 points -weak cry = 1 point -muscle tone sufficient = 2 points -body pink = 2 points -grimaces when stimulated = 1 point

Which factors place an infant at risk for sudden infant death syndrome?

-cigarette smoking -prone sleep position -lower socioeconomic status

Which are the leading causes of accidental death in infants under 1 year of age?

-drowning -motor vehicle-related injuries -suffocation

Which characteristics would the nurse expect infants with failure to thrive to exhibit?

-language deficit -tendency to illness

Which parent teaching would the nurse provide about signs of shunt failure in a 4-month-old infant with a ventroperitoneal shunt?

-vomiting -distended fontanels

Which physiologic responses to bronchiolitis would the nurse expect to observe in the pediatric intensive care unit?

-wheezing -sternal retractions -nasal flaring -prolonged expiratory phase

Which toy would be developmentally appropriate for a 6-month-old infant?

Soft stuffed animals

When picked up by a parent or the nurse, an 8-month old infant screams and seems to be in pain. After observing this behavior, which would the nurse discuss with the parent?

Any other behaviors that the parent might have noticed

Which finding would the nurse expect when assessing an infant with suspected developmental dysplasia of the hip?

Apparent shortening of a leg

The nurse is caring for a 9-month-old infant with gluten-induced enteropathy. Which common term for this disorder would the nurse use when discussing the infant's diagnosis with the parents?

Celiac disease

At 20 hours of age, a newborn is found to have a bilirubin concentration of 13 mg/dL (274 mcmol/L). Which clinical finding most likely contributed to this bilirubin level?

Cephalhematoma

Which statement would indicate to the nurse that the parents of an infant admitted with gastroenteritis understand contact precautions when they note that after washing their hands they need to do which?

Change their gloves each time they change the baby's diaper

Which nursing action would the nurse perform for an infant who develops mottling in the leg used for cardiac catheterization?

Checking the pulse in the extremity

Which diet would the nurse anticipate for a 4-week-old infant after surgical repair for hypertrophic pyloric stenosis?

Electrolyte solution

Which nursing intervention helps foster the development of a trusting parent-child relationship?

Encouraging face-to-face contact between the parents and infant

Which education would the nurse provide the parents of an infant about the cause of galactosemia?

Error in carbohydrate metabolism

Which intervention would the nurse provide to facilitate the drying of a cast recently applied to a child with clubfoot?

Exposing the casted extremity

Which treatment would the nurse anticipate for an infant admitted with bronchiolitis caused by respiratory syncytial virus (RSV)?

Humidified cool air and adequate hydration

Which education would the nurse provide parents about the side effects of the Haemophilus influenzae (Hib) vaccine?

Low-grade fever

Which nursing action is the priority in the care of a young child with severe diarrhea?

Maintaining fluid and electrolyte balance

Which intestinal obstruction is a concern for hospitalized preterm infants?

Necrotizing enterocolitis

Which complication would the nurse recognize as the most serious in an infant with meningitis?

Peripheral circulatory collapse

Which physical assessment finding would the nurse expect in a 9-month-old infant with severe dehydration?

Weak, rapid pulse

A 4-month-old infant is admitted with a diagnosis of bronchiolitis. Which feeding recommendation would the nurse give the mother?

Withhold feedings at this time.

Which positioning would the nurse provide a 2-month-old infant admitted with a diagnosis of respiratory syncytial virus infection?

-Semi-Fowler -head in sniffing position

The nurse is caring for a 3-month-old infant whose abdomen is distended and whose vomitus is bile stained. Which clinical manifestations support the suspicion of intestinal obstruction?

-paroxysmal pain -grunting respirations

Which surgical procedure involves urinary diversion in which the ureters are transplanted to a resected section of the small intestines, with one end attached to the abdominal wall?

Ileal conduit

An infant is found to have developmental dysplasia of the hip 6 weeks after birth. The parents ask the nurse why their infant must be restrained in a harness at such an early age. How would the nurse respond?

Infants' hip joints are cartilaginous, allowing molding of the acetabulum.

Which description would the nurse provide the parents of an infant who are asking about what a patent ductus arteriosus (PDA) is?

It is a connection between the pulmonary artery and the aorta.

Which education would the nurse provide the parents of a child diagnosed with atopic dermatitis (eczema)?

It is most common in infants

During a newborn assessment for developmental dysplasia of the hip, the nurse notes a clunk with the Ortolani test. How would the nurse explain this finding to the child's mother?

It is the femur head relocating in the hip.

A 4-month-old infant is brought to the emergency department after 2 days of diarrhea. The infant is listless and has sunken eyeballs, a depressed anterior fontanel, and poor tissue turgor. Breathing is deep, rapid, and unlabored. Stools are liquid and there has been no obvious urine output. Which problem would the nurse be concerned about?

Metabolic acidosis

Which procedural description would the nurse provide the parents of an infant who has a cardiac catheterization scheduled?

"A catheter will be inserted into a blood vessel in your baby's groin and then threaded to the heart to confirm an anatomic abnormality."

Which response would the nurse give the mother of an infant with meningitis who is concerned that her toddler at home will feel neglected when she stays at the hospital?

"Can you arrange with someone to stay here when you are at home?"

Children's patterns of play change as they grow from infancy through school age. In what order do they appear, starting from infancy?

-Solitary -Parallel -Associative -Cooperative

Which parent education would the nurse provide about typical behaviors of an 8-month-old infant?

-being shy with strangers -showing interest in small objects

Which birth factors place the neonate at risk for sudden infant death syndrome (SIDS)?

-birth order -multiple births -low Apgar scores

A 4-month-old infant weighing 11 lb (5 kg) should receive 108 kcal/kg per day. If the formula contains 20 kcal/oz (20 kcal/30mL), how much formula would the nurse tell the mother to give to her infant each day?

27 oz (810 mL)

Which hematocrit result would the nurse recognize as normal in a healthy 12-month-old infant?

29-41%

A 20-lb infant has a normal saline enema order, at a dose of 10 mL/kg. Which dose would the nurse administer?

90 mL

How would the nurse determine the length of tube needed to reach the stomach for nasogastric feeding?

A measurement is made from nose to earlobe and then to the epigastric area.

Which is the priority intervention for the infant with developmental dysplasia of the hip?

Abduction of the hip

Which assessment finding would the nurse recognize as common in infants with Down syndrome?

Abnormal heart sounds

Which type of cerebral palsy (CP) is associated with slow writhing movements?

Athetoid

Which feeding habit would the nurse expect to find while assessing a 6-month-old infant?

Feeds self crackers

The parent of an infant with heart failure questions the necessity of weighing the baby every morning. Which would the nurse say that this daily information is important in determining?

Fluid retention

A 12-month-old infant has become immunosuppressed during a course of chemotherapy. Which education would the nurse provide the parents about the measles, mumps, and rubella vaccine?

Infants who are receiving chemotherapy should not be given these vaccines

Which clinical finding suggests developmental dysplasia of the hip in an infant?

Leg length discrepancy

Which are the characteristics of reactions associated with immunizations for a 2-month-old infant?

Local or systemic and usually mild

Which cereal would the nurse recommend to the parent of an infant who plans to introduce solid foods?

Rice

Which management strategy is the treatment of choice for hypertrophic pyloric stenosis (HPS)?

Surgery

When checking placement of a feeding tube, the nurse is unable to hear the air injected because of noisy breath sounds. Which would the nurse do next?

Try aspirating stomach contents

Which activity would the nurse encourage as age appropriate for a 10-week-old infant?

Tummy time

Which is the typical time line for a newborn to undergo cleft lip repair?

Usually before the baby is 12 weeks old

How can the nurse best provide psychologic comfort for a 2-month-old infant who is being observed in the hospital after an automobile collision without the family present?

following a routine to which the infant is accustomed

Where on the bottom of an infant's foot would the nurse place the automatic lancet device to obtain a blood specimen for a hypoglycemia test?

lateral aspect of heel (side of heel)

Which clinical assessment would the nurse perform to evaluate the effectiveness of a shunt for an infant with hydrocephalus?

palpating the anterior fontanel

Which education would the nurse provide the parents of an infant with bilateral cryptorchidism about the infant's prognosis if the problem is not corrected?

sterility upon maturity

The nurse is teaching skin and basic care to the parent of a 6-month-old infant with eczema. Which statement indicates that the parent needs further teaching?

"I'll have to be careful not to cut my baby's nails short."

Which information would the nurse include when educating the parents of a 10-month-old about accidental poisoning?

-Keep the poison control number handy -avoid storing chemicals in containers also used to keep food

Which developmental milestones would the nurse expect in a 9-month-old infant?

-enjoys push-pull toys -sits steadily without support -responds to simple commands

How is metabolic acidosis in infants manifested?

-lethargy -Kussmaul breathing -loss of alkaline fluid through diarrhea

According to Piaget's theory of cognitive development, which milestone would the nurse expect a 6-month-old infant to demonstrate?

Beginning of object permanence

After several episodes of abdominal pain and vomiting, a 5-month-old infant is admitted with a tentative diagnosis of intussusception. Which assessment would the nurse document that will aid confirmation of the diagnosis?

Characteristics of stools

The weight of a 3-month-old infant with tetralogy of Fallot has declined from the 25th percentile to the 5th. Which mechanism would the nurse suspect is the reason for this inadequate weight gain?

Inadequate oxygen perfusion, leading to activity intolerance, resulting in diminished energy

Which toys are developmentally appropriate for a 3-month-old infant?

-metallic mirror -colorful mobile -anything that sparks self-recognition and visual stimulation

Which positions would the nurse use for a neonate with an imperforate anus during the postoperative period for a colostomy?

-supine with head of crib elevated -side-lying with head of crib elevated

Which nursing assessments are indicated for an infant being admitted with pyloric stenosis and 3 days of vomiting?

-tissue turgor -neurologic status -amount of last void

Which explanation would the nurse provide the mother of an infant who vomits the first feeding after corrective surgery for hypertrophic pyloric stenosis?

"This often occurs after the first feeding."

An infant has been admitted with failure to thrive. The nurse knows that more education is needed when one of the parents makes which statement?

"I can double the amount of water in the formula to save money."

Which parental statement would the nurse recognize as placing an infant at risk for injury?

"I heat the formula in the microwave for 30 seconds."

Which statement made by the parent would prompt the nurse to provide education?

"I rinse the changing table with warm, soapy water."

A newborn with Erb palsy has an asymmetric Moro reflex. Which cause would the nurse suspect?

An injury to the shoulder during birth

Which comorbidity is associated with Down syndrome?

Congenital heart disease

An infant who weighs 12 lb 4 oz (5.6 kg) is receiving 8 oz (240 mL) of full-strength formula, 20 kcal/fl oz every 4 hours between 8:00 AM and midnight. In light of the recommended caloric intake of 108 kcal/kg/day, which would the nurse conclude about the amount of formula ingested?

Exceeds recommended requirements

Which teaching would the nurse include for parents of an infant with a cleft lip and palate?

Expectation that once feeding is established, they should otherwise be healthy

Which parent education would the nurse provide for a 1-year-old infant who drinks from four to six full bottles of milk per day and has a hemoglobin level of 9 g/dL (90 mmol/L)?

Give the infant finger foods such as baby cereal and soft meats

Which plan of care would the nurse provide for a newborn with hypospadias?

Giving the parents reasons why circumcision should not be performed (foreskin may be needed for reconstruction of penis)

In children with celiac disease, an intolerance to what is found?

Grains

Which intervention would the nurse prioritize to soothe a hospitalized infant who appears to be in pain?

Holding the infant

Which preoperative goal would the nurse establish while caring for an infant born with a myelomeningocele?

Keeping the infant infection-free

Which clinical sign or reflex entails spasm of the hamstring muscles during leg extension?

Kernig sign

A nurse confirms that a 9-month-old infant's immunization schedule is up to date. Which immunization will the infant receive at 15 months of age?

Measles, mumps, and rubella (MMR)

Which nursing intervention would the nurse provide to an 8-month-old infant after surgical correction for hypospadias?

Minimizing pain with adequate analgesia

Which factor is the strongest predictor of illness in a childcare setting?

Number of unrelated children in a room

Which assessment would be the most accurate method of monitoring the hydration status of a 2-month-old infant admitted with diarrhea and dehydration?

Obtaining daily weights

A 9-month-old infant appears well-nourished, alert, and happy. Using Freud's psychosexual stages of development, the nurse determines that the infant is in which stage?

Oral-sensory stage

Which assessment finding is a late sign of heart failure?

Peripheral edema

For which additional defect would the nurse assess an infant with exstrophy of the bladder?

Pubic bone malformation

Which parent education would the nurse provide the mother of an infant recently treated for severe dehydration related to diarrhea?

Signs of dehydration in infants

Which client/parent education would the nurse include about a potential complication of mumps?

Sterility

Which is the nurse's priority intervention after discovering an infant is apneic?

Stimulate the trunk

Which education would the nurse provide the parents of an infant who just underwent insertion of a ventriculoperitoneal shunt for hydrocephalus?

The shunt may need to be replaced as the child grows older.

Which safety education would the nurse provide to the parent of a 3-month-old infant?

Test the temperature of water before bathing.

Which order should parents introduce new foods to a 5-month-old who is now eating fortified cereal mixed with formula?

Vegetables and non-citrus fruits after cereals -they are easily digested

Which nursing action is most effective in controlling the spread of infection for an infant with diarrhea?

Washing hands before and after contact with the infant