infant

Question 9 See full question 21s The mother of a newborn is voicing concerns about her baby's ability to hear. What should the nurse tell the mother?

Correct response: Most American states and Canadian jurisdictions mandate hearing tests for infants. Explanation: The American Academy of Pediatrics and the American College of Obstetrics and Gynecology recommend hearing screening for all newborns. Currently more than 30 states mandate screening, which is done by otoacoustic emissions or auditory brainstem response. Newborns can hear as soon as the amniotic fluid drains from the ear canal. Even though hearing problems are not common in newborns, the mother's concerns should be addressed. Clapping to elicit a response is crude and unreliable. If done for minimal screening, the distance should be no more than 12 inches.

Question 10 The nurse is assessing children at risk for phenylketonuria (PKU). Which child is at greatest risk?

Correct response: blond, blue-eyed, fair-skinned child with eczema Explanation: Infants with PKU are usually blond, blue-eyed, and fair, and often have eczema. The other physical assessment findings are not typically found in children with PKU.

http://ruby.fgcu.edu/courses/80277/lungassess.html ASSESSMENT OF THORAX AND LUNGS Anatomy and Physiology Health History Current Health Status - shortness of breath - cyanosis - cough - sputum - chest pain Past Health History - prior lung disease - exposure to respiratory disease - allergies - smoking - OTC nasal sprays or medications - use of oxygen - vaccinations Examination Position: Remove all clothing to waist. Sit on an exam table or stand. Inspection: Shape of chest - A. AP Diameter - (Antero-posterior diameter) B. Barrel Chest - AP diameter compared to transverse diameter is 1:1 C. Pigeon Breast (Pecus carinatum) - AP diameter is increased D. Funnel Breast - (Pecus excavatum) E. Kyphosis F. Poker Spine G. Scoliosis H. Lordosis Slope of Ribs - normally ribs are inserted into the spine at a 45E angle and inserted into the costal angle at a 45E angle. Abnormal Retraction of Interspaces During Inspiration A. Substernal retractions B. Intercostal retractions C. Suprasternal retractions Pattern of Respiration A. Men & women - breathe diaphragmatically Women - breathe thoracically or costaly Rate Depth, Type and Rhythm of Breathing A. Eupnea, 16-20 BPM B. Tachypnea, respirations over 20 BPM C. Bradypnea, respirations under 10 BPM D. Apnea, absence of respirations E. Hyperpnea, increase in depth of respirations F. Cheyne-Stokes, altering hyperpnea and shallow respirations, followed by periods of apnea. G. Biot's, shallow breathing interrupted by apnea H. Kussmauls, increase in rate and depth Apneustic, long inspiration, short expiration Use of Accessory Muscles. A. Sternocleidomastoid muscle B. Scalenus Trapezius Symmetry of Chest Expansion Lips, Nailbeds, Nares Palpation: Identify Areas of Tenderness, Lesions, Masses, or Crepitation Respiratory Excursion. (Thoracic expansion) Can be assessed in anterior or posterior chest. Tactile Fremitus (vocal fremitus) - client says "99" while examiner palpates the thorax using palmar surface of fingers or ulnar aspect of hand. A. Normal fremitus B. Increased vocal fremitus C. Decreased or absent vocal fremitus Vibration (fremitus) During Quiet Inspiration and Expiration Palpate for Tracheal Deviation. Percussion: Percussion penetrates to a depth of approximately 5-7 cm. It is used to determine the relative amounts of air, liquid, or solid material in the underlying lung. Resonance - loud, low pitched hollow sound of a long duration. Abnormal percussion notes: Hyperresonance - occurs with increased amounts of air. Loud, low-pitched booming sound with a long duration. Dullness - occurs with fluid, pus, consolidation, or tumors. Medium soft intensity with a thud-like sound. Flatness- large amount of fluid over an area with little underlying air. (Pleural effusion). Soft, high-pitched sound with a very short duration. Diaphragmatic excursion Auscultation: Symmetrical Areas Should be Compared in Regard to Pitch Intensity Quality Duration Presence of Adventitious Breath Sounds. Instruct client to breathe slightly more deeply and slowly than normal respiration. Client should breathe through open mouth. Sound Duration of inspiration and expiration Diagram of sound Pitch Intensity Normal Location Abnormal Location Vesicular Inspiration > expiration 5 : 2 Low Soft Peripheral lung Over trachea and sternum Broncho-vesicular Inspiration = expiration 1 : 1 Moderate Moderate First and second intercostal spaces at the border over major bronchi Peripheral lung Bronchial (tubular) Inspiration < expiration 1 : 2 Pause between inspiration and expiration High Loud Over trachea Lung areas Changes in Normal Breath Sounds A. Deep breathing changes normal vesicular sounds to bronchovesicular sounds B. Breathing through the nose will alter normal breath sounds C. Fluid filling the alveoli will convert vesicular sounds to bronchovesicular sounds (early pneumonia). D. Large amounts of fluid collecting will change vesicular to bronchial sounds (lung consolidation). E. No breath sounds obstructed bronchus pneumothorax fractured ribs with splinting obesity barrel chest thickened pleura air and fluid in pleural place Egophony - when listening over a normal peripheral lung you will hear the sound "eee" when the patient voices "eee." When the lung is compressed by fluid (pleural effusion), you will hear the sound "aye." Adventitious Sounds A. Crackles (rales) Fine - high pitched Medium Coarse - low pitched B. Wheezes Sonorous (coarse) - low pitched Sibilant (wheezes) - high pitched (usually occurs during expiratory phase of respiration. Inspiratory wheezes indicate severe narrowing of the airway.) a. monophonic wheezes b. polyphonic wheezes C. Rhonchi (gurgles) D. Friction rub - loud dry creaking or grating sound heard best over lower anterolateral thorax E. Stridor - an inspiratory wheeze that is louder over the neck than the thorax.

assessment of lungs and chest

Question 1 An infant boy has just had surgery to repair his cleft lip. Which nursing intervention is important during the immediate postoperative period? Correct response: Cleaning the suture line carefully with a sterile solution after every feeding Explanation: To avoid an infection that could adversely affect the cosmetic outcome of the repair, the suture line must be cleaned very gently with a sterile solution after each feeding. Laying an infant on his abdomen after a cleft lip repair isn't appropriate because doing so will put pressure on the suture line, causing damage. The infant can be positioned on his side to drain saliva without affecting the suture line. Crying puts tension on the suture line and should be avoided by anticipating the baby's needs, such as holding and cuddling him. Hard objects such as pacifiers should be kept away from the suture line because they can cause damage. Question 2 When performing cardiopulmonary resuscitation on a 7-month-old infant, which location would the nurse use to evaluate the presence of a pulse? Correct response: Brachial artery Explanation: The brachial artery is the best location for evaluating the pulse of an infant younger than age 1. A child of this age has a very short and often fat neck, so the carotid artery is inaccessible. The femoral artery is usually inaccessible because of clothing and diapers. The radial artery may not be palpable if cardiac output is low, even if there is a heart beat. Question 3 Which step should a nurse take first when administering a liquid medication to an infant? Correct response: Verify the physician order. Explanation: The nurse should first verify the physician's order. Next, the nurse should make sure she has the right drug, dose, route, and time. She should then make sure she has the right client by checking the infant's armband. After these steps, the nurse should hold the infant securely in the crook of her arm and raise the infant's head to about a 45-degree angle. Then, the nurse should place the dropper at the corner of the infant's mouth so the drug runs into the pocket between the infant's cheek and gum. Doing this keeps him from spitting out the drug and reduces the risk of aspiration. Question 4 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? 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. Question 5 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. 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 five stages of psychosocial development, trust versus mistrust (birth to age 1), the child develops trust as the primary caregiver meets his needs. In the second stage, autonomy versus shame and doubt (ages 1 to 3), the child gains control of body functions and becomes increasingly independent. In the third stage, initiative versus guilt (ages 3 to 6), the child develops a conscience and learns about the world through play. In the fourth stage, 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, the child enters the fifth stage, identity versus role confusion (ages 12 to 19), and becomes preoccupied with looks, how others view him, meeting peer expectation, and establishing his own identity. Question 6 Which action should the nurse take next after noting that an 8-month-old child's posterior fontanel is slightly open? Correct response: Check the child's head circumference. Explanation: This is not a normal finding because the posterior fontanel usually closes by age 2 months. Therefore, the nurse should measure the head circumference to determine if the child's head is larger than the established norms because hydrocephalus can cause separation of the cranium sutures. Because the child is 8 months old, the labor and birth history probably would not be a significant factor. An x-ray (radiologic) examination is not necessary until other data are collected. Question 7 After receiving a report, the nurse is making out assignments. Which client would be appropriate to assign to unlicensed assistive personnel? Correct response: an 8-month-old with pneumonia who will be discharged today Explanation: The most appropriate client to assign to unlicensed assistive personnel would be the infant who is stable. Registered nurses have the responsibility for assessment, evaluation, and making nursing judgments. Unlicensed assistive personnel can care for a client with pneumonia who will be discharged because this child is stable. The child with a fractured femur, the adolescent with fluctuating vital signs and a new central line, and the infant who recently underwent surgery should be cared for by a registered nurse who can make appropriate judgments and perform required procedures. Question 8 The nurse is assessing a 6-month-old and notices no pincer grasp on either hand. The mother asks the nurse if this is abnormal. The nurse correctly responds that: Correct response: The six month old does not normally have a pincer grasp yet. Explanation: The nurse would be incorrect to inform the mother that the infant could be at risk for developmental disabilities, because the pincer grasp does not present itself until around 9 months of age. Deferring the question to the physician is ignoring the mother's concern, and the nurse can manage this question. There is no need to ask the physician about the infant's other sibilings. Question 9 A 10-month-old child with bronchiolitis with a prescription to wean oxygen was weaned to room air 2 hours ago. During a feeding, the nurse notes that the child is exhibiting an increased respiratory rate, is becoming more irritable, and is using accessory muscles to breathe. The pulse oximeter is reading 91%. The first actions of the nurse should be to: Correct response: discontinue the feeding and place the child back in the tent. Explanation: The child who has increasing respiratory difficulty after being weaned from oxygen should be placed back on oxygen. The child's pulse rate will most likely be increased. The nurse does not need to notify the primary care provider of the child's status unless no improvement occurs after the child is back on oxygen. Albuterol has limited use in the treatment of bronchiolitis and can be associated with vomiting if given too close to feedings. Unless the child has blocked nasal passages, there is no reason to suction the nares. Question 10 A nurse is teaching child care classes for adolescent mothers. To enhance the adolescents' understanding of infant safety, the nurse would suggest that the mother: Correct response: Crawl around on the floor looking for potential hazards from the eyes of an infant. Explanation: Crawling on the floor is a participative activity that can help promote understanding of infant safety in relation to the infant's perspective. The nurse doesn't need to instruct adolescents to discuss infant safety with the pediatrician because the nurse can provide such information in the class environment. Presenting a lecture or video doesn't directly focus on the infant's perspective regarding items that may be a safety threat.

LvL 6 to 7

A nurse performs cardiopulmonary resuscitation (CPR) for 2 minutes on an infant without calling for assistance. In reassessing the infant after 2 minutes of CPR, the nurse finds he still isn't breathing and has no pulse. The nurse should then: You Selected: Call for assistance. A first-time mother is concerned that her 6-month-old infant is not gaining enough weight. What should the nurse tell the mother? You Selected: "Birth weight doubles by 6 months of age." A nurse observes a family in the playroom. Which behavior would be considered to be an example of social affective play? You Selected: An infant is making happy noises in response to her father speaking to her. A parent tells the nurse that their 8-month-old infant is anxious. Which suggestion by the nurse is most appropriate to help the parent lessen anxiety in the infant? You Selected: Talk quietly to the infant while he is awake. Which serum electrolytes findings should the nurse expect to find in an infant with persistent vomiting? You Selected: K+, 3.2; Cl-, 92; Na+, 120 Question 1 See full question 3m 10s For the last 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: You Selected: the inside of the infant's mouth. Correct response: the inside of the infant's mouth. Explanation: Add a Note Question 2 See full question 2m 18s A 3-month-old infant with meningococcal meningitis has just been admitted to the pediatric unit. Which nursing intervention has the highest priority? Correct response: instituting droplet precautions Question 3 The mother of an 11-month-old infant reports to the nurse that her infant sleeps much less than other children. The mother asks the nurse whether her infant is getting sufficient sleep. What should be the nurse's initial response? You Selected: Ask the mother for more information about the infant's sleep patterns. Question 4 The parent of a 2-week-old infant brings the child to the clinic for a checkup. The parent expresses concern about the baby's breathing because the infant breathes quickly for a while and then breathes slowly. The nurse interprets this finding as an indication of what factor? You Selected: a normal pattern in infants of this age Question 5 When preparing to deliver back slaps to an infant who is choking on a foreign body, the nurse should place the infant in which position? You Selected: head down and lower than the trunk Question 6 The nurse is caring for an infant admitted with a severe respiratory infection. The nurse is explaining the risk of airway obstruction and the need for frequent respiratory assessments to the parents. Which of the following statements by the nurse is most appropriate regarding the risk of airway obstruction? You Selected: "The infant's larger tongue and smaller oral cavity increase the risk of airway obstruction." Question 7 A nurse is teaching the parents of an infant with cystic fibrosis about chest percussion therapy. Which statement by the nurse is most effective in explaining the rationale for using chest percussion on infants with cystic fibrosis? You Selected: "Chest percussion helps clear secretions out of the lungs." Question 8 A mother is discontinuing breast-feeding after 3-1/2 months. The mother is seeking education on what to feed her baby now that she is no longer breast-feeding. The nurse teaches the mother about infant feeding and suggests the following: You Selected: Iron-fortified formula alone Question 9 A nurse is caring for an infant who requires intravenous therapy. The nurse notes that the only available IV pump is in a toddler's room. In which order should the nurse complete the following actions? 1. Remove pump from toddler's room 2. Clean the pump 3. Take pump into infant's room 4. Use the pump You Selected: 1, 2, 3, 4 Question 10 An infant underwent surgery to remove a myelomeningocele. The infant has bulging fontanels. Which of the following is the nurse's best action? Correct response: Notify the healthcare provider

level 1 to 2

Question 1 A mother calls the clinic to report that her 9-month-old infant has diarrhea. Upon further questioning, the nurse determines that the child has mild diarrhea and no signs of dehydration. Which advice is most appropriate to give this mother? Correct response: "Continue your infant's normal feedings." Explanation: If an infant has mild diarrhea, his mother should be advised to continue his normal diet and to call back if the diarrhea doesn't stop or if he shows signs of dehydration. There's no need to give the infant clear liquids only. Notifying the day care about the infant's illness is important but doesn't take priority. Question 2 A nurse is teaching the parents of an infant with clubfeet about cast care. Which statement by the father indicates the need for further teaching? Correct response: "Immunizations will have to be delayed until the casts come off." Explanation: The father's statement about delaying immunizations indicates the need for further teaching. Immunizations can be administered in the thighs because the casts cover only the lower legs and feet. The other responses are correct statements, indicating effective teaching. Question 3 A parent brings a 3-month-old infant to the clinic, reporting that the infant has a cold, is having trouble breathing, and "just does not seem to be acting right." Which action should the nurse take first? Correct response: Assess the infant's oxygen saturation. Explanation: In an infant with these symptoms, the first action by the nurse would be to obtain an oxygen saturation reading to determine how well the infant is oxygenating. Because the parent probably can provide no other information, checking the heart rate would be the second action done by the nurse. Then the nurse would obtain the infant's weight. Question 4 Which statement by the parent of an infant with a repaired upper lumbar myelomeningocele indicates that the parent understands the nurse's teaching at the time of discharge? Correct response: "I will call the health care provider if his urine has a funny smell." Explanation: Children with a myelomeningocele are prone to urinary tract infections (UTI) and foul-smelling urine is one symptom of a UTI. Because of the level of defect, the child may be insensitive to pressure or heat. Using a heating pad may lead to thermal injury because the child may not be able to sense if the pad is too hot. Keeping the child away from other children is unnecessary and can retard social development. Using pillows as props increases the risk of sudden infant death syndrome. Question 5 Two parents who are arguing in their infant's room, with voices raised and getting louder, start to hit each other. The infant is crying. Which action should the staff nurse take next? Correct response: Remove the infant from the room. Explanation: The situation is escalating, and the nurse's priority is to protect the infant from harm. Therefore, removal of the infant from this situation should be the first action by the nurse. Reasoning at this point or asking one of the parents to leave the room would be ineffective and may serve to further escalate the situation. Calling security is necessary, but only after the nurse has removed the infant from the room. Question 6 Which child is most at risk for sudden infant death syndrome (SIDS)? Correct response: infant who is three months old Explanation: The highest incidence of SIDS occurs in infants between ages 2 and 4 months. About 90% of SIDS occurs before the age of 6 months. Apnea lasting longer than 20 seconds has also been associated with a higher incidence of SIDS. SIDS occurs with higher frequency in families where a child in the family has already died of SIDS, but the age of the parents has not been shown to contribute to SIDS. A respiratory infection such as pneumonia has not been shown to cause a higher incidence of SIDS. Question 7 A 10-month-old child with phenylketonuria (PKU) is being weaned from breast-feeding. When teaching the parents about the proper diet for their child, the nurse should stress the importance of restricting meats and dairy products because: Correct response: they contain high levels of phenylalanine. Explanation: PKU is an inherited disorder characterized by the inability to metabolize phenylalanine, an essential amino acid. Phenylalanine accumulation in the blood results in central nervous system damage and progressive intellectual disability. However, early detection of PKU and dietary restriction of phenylalanine can prevent disease progression. Intake of high-protein foods, such as meats and dairy products, must be restricted throughout life because they contain large amounts of phenylalanine. Question 8 The health care provider (HCP) prescribes an intravenous infusion of 5% dextrose in 0.45 normal saline to be infused at 2 mL/kg/h in an infant who weighs 9 lb (4.1 kg). How many milliliters per hour of the solution should the nurse infuse? Round to one decimal place. Your Response: 8.0 Correct response: 8.2 Explanation: 4.1 kg × 2 mL/kg = 8.2 mL/hour Add a Note

LvL 7 to 8

Question 1 See full question 4m 3s A nurse is teaching the mother of a 5-month-old infant diagnosed with bronchiolitis. Which statement by the mother indicates that teaching has been effective? You Selected: "I know that this disease is serious and can lead to asthma." Correct response: "I know that this disease is serious and can lead to asthma." Explanation: Add a Note Question 2 A nurse is teaching the mother of an infant. The nurse should instruct the mother to introduce her infant to solid foods at what age? Correct response: 6 months Question 3 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, which description about the stoma's appearance should the nurse include in the teaching? Correct response: staying deep red in color Question 4 When developing the plan of care for a child diagnosed with phenylketonuria (PKU), the nurse should establish which goal? Correct response: meeting the child's nutritional needs for optimal growth Question 5 Before placement of a ventriculoperitoneal shunt for hydrocephalus, an infant is irritable, lethargic, and difficult to feed. To maintain the infant's nutritional status, which action would be most appropriate? Correct response: Give the infant small, frequent feedings. Question 6 Which action should the nurse include when developing the plan of care for a neonate prior to surgical repair of a myelomeningocele? Correct response: Cover the defect with moist, sterile saline dressings. Question 7 Which nursing intervention is most important postoperatively for an infant who has received a ventriculoperitoneal shunt? Correct response: Monitor intake and output. Question 8 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? Correct response: Have the child fitted for a larger cast. Question 9 During a well-baby visit, a 2-month-old infant receives a diphtheria, tetanus toxoids, and acellular pertussis (DTaP) vaccine, inactivated poliovirus vaccine, hepatitis B vaccine, pneumococcal vaccine, and Haemophilus influenzae b (Hib) vaccine. The parents ask why the baby must have the Hib vaccine. The nurse responds by stating: Correct response: "This vaccine protects against serious bacterial infections, such as meningitis." Question 10 A nurse is performing a neurologic assessment on an infant. When assessing for function of cranial nerve X (vagus), which technique is most appropriate to use? Correct response: Press a tongue blade on the posterior surface of the tongue.

level 4 to 5

Question 1 See full question 5m 4s 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? Correct response: No action is needed; this is a normal finding. Question 2 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? You Selected: I.V. tubing with a volume-control chamber Correct response: I.V. tubing with a volume-control chamber Question 3 An older infant who has been injured in an automobile accident is to wear a splint on the injured leg. The mother reports that the infant has become mobile even while wearing the splint. What should the nurse advise the mother to do? You Selected: Remove any unsafe items from the area in which the infant is mobile. Correct response: Remove any unsafe items from the area in which the infant is mobile. Explanation: Add a Note Question 4 See full question 7m 56s A diagnosis of hemophilia A is confirmed in an infant. Which of the instructions should the nurse provide the parents as the infant becomes more mobile and starts to crawl? You Selected: Sew thick padding into the elbows and knees of the child's clothing. Correct response: Sew thick padding into the elbows and knees of the child's clothing. Explanation: Add a Note Question 5 See full question 3m 30s 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? You Selected: Examine the fontanels and sutures. Correct response: Examine the fontanels and sutures. Explanation: Add a Note Question 6 See full question 39s The nurse is caring for an emergency room infant who has symptoms of irritability and a high fever. When assessing for increased intracranial pressure using the anterior fontanel, identify the area where a nurse would palpate. You Selected: Your selection and the correct area, market by the green box. Explanation: Add a Note Question 7 See full question 2m 17s A 2-month-old infant is at risk for an ileus after surgery to correct intussusception. What should be included in a focused assessment for this complication? Select all that apply. You Selected: characteristics of the first stool measurement of gastric output assessment of bowel sounds Correct response: assessment of bowel sounds characteristics of the first stool measurement of gastric output Question 8 Which signs or symptoms suggest that an infant with diarrhea is dehydrated? Select all that apply. Correct response: tacky mucous membranes sunken anterior fontanel restlessness Explanation: Question 9 A nurse is teaching a new mother how to prevent burns in the home. Which statement by the mother indicates more teaching is required? Correct response: "I will heat my infant's formula in the microwave." Question 10 A nurse is caring for an infant who weighs 8 kg and is ordered to receive ampicillin 25 mg/kg intravenously every 6 hours. How many milligrams would a nurse administer per dose? Record the answer as a whole number. Correct response: 200

level 3 to 4