Infant

The nurse is planning care with the parents of a 4-month-old infant with heart failure and congenital heart disease. The parents report that their child tires easily. Which intervention is a priority for this child? Increase the number of rest periods. Prevent infection. Restrict the child's movements. Add layers of clothing

Increase the number of rest periods.

A 6-month-old infant is brought to the clinic. The mother reports the infant has been lethargic and not eating well. The infant's anterior fontanel is sunken. Which additional information is a priority for the nurse to assess? Number of feeds in the last 24 hours Number of hours infant has slept in the last 24 hours Skin color and cap refill Number of wet diapers the in the last 24 hours

Number of wet diapers the in the last 24 hours

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? Press a tongue blade on the posterior surface of the tongue. Observe for spontaneous eye movement. Lightly brush a cotton swab across the child's cheek. Assess for smiling or forceful eye closing with crying.

Press a tongue blade on the posterior surface of the tongue.

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 3-cm increase in abdominal circumference periods of occasional fussiness absence of bowel sounds since surgery bright red stoma

a 3-cm increase in abdominal circumference

When preparing to admit an infant diagnosed with diarrhea to the pediatric unit, the nurse should assign the infant to which room? a single negative pressure room a two-bed room with an infant with respiratory disease a private room a room with other infants younger than age 1 year

a private room

The nurse is evaluating an infant for auditory ability. What is the expected response in an infant with normal hearing? blinking and stopping body movements when sound is introduced evidence of shy and withdrawn behaviors saying "da-da" by age 5 months absence of squealing by age 4 months

blinking and stopping body movements when sound is introduced

The nurse judges that the mother has understood the teaching about care of an infant with colic when the nurse observes the mother doing which action? holding the infant prone while feeding holding the infant in her lap to burp placing the infant prone after the feeding burping the infant during and after the feeding

burping the infant during and after the feeding

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? excessive cerebrospinal fluid within the cranial cavity abnormally small head congenital absence of the cranial vault overriding of the cranial sutures

excessive cerebrospinal fluid within the cranial cavity

Which activity by the mother offers the most support to the child during the first few days after surgery to repair a cleft lip? holding and cuddling the child helping the child play with some toys reading some of the child's favorite stories staying at the bedside and holding the child's hand

holding and cuddling the child

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

increased GI motility

A 10-month-old infant is brought to the well-baby clinic for a follow-up visit. The mother tells the nurse that she has been having trouble feeding her infant any solid foods. The infant only prefers breastfeeding and pushes food from the mouth. To help correct this problem, the nurse should: instruct the mother that tongue thrusting is the infant's way of rejecting food. instruct the mother to place the food further back and to the side of the infant's mouth. instruct the mother to offer small, bite-size food. instruct the mother to limit the infant's breast milk.

instruct the mother to place the food further back and to the side of the infant's mouth.

A nurse is conducting a physical examination on a 2-month-old infant at the well-child examination. When measuring chest circumference, what is the standard anatomical landmark used?

nipple line

A parent asks the nurse why a 10-month-old infant gets otitis media more frequently than a 10-year-old child. How should the nurse respond? "An infant's eustachian tubes are shorter." "Infants are unable to blow their own noses." "Pressure builds up in the ear canal when infants lie flat." "Infants under one year have immature immune systems."

"An infant's eustachian tubes are shorter."

After teaching a community class to new parents, the nurse evaluates client understanding of strategies to prevent sudden infant death syndrome (SIDS). Which statements indicates appropriate understanding? "I will place my baby in a supine position for sleep during the first year." "I will use a baby monitor so I can hear if my baby stops breathing." "I will avoid feeding my baby cereal for the first 6 months." "I will keep my baby's crib at our bedside when we sleep."

"I will place my baby in a supine position for sleep during the first year."

The nurses discusses appropriate iron-rich food selections with the parent of an 11-month-old infant with iron deficiency anemia. The nurse determines that teaching has been successful when the parent verbalizes that she will include which foods in the child's diet? eggs, fortified cereals, meats, and green vegetables fruits, cereals, milk, and yellow vegetables eggs, fruits, milk, and mixed vegetables juices, fruits, fortified cereals, and milk

"I will place my baby in a supine position for sleep during the first year."

During discharge teaching with new caregivers, the caregivers express concern over a recent whooping cough outbreak. The caregivers asks when the client can receive the vaccine for whooping cough. The nurse states that which is the recommended immunization schedule for diphtheria, tetanus toxoids, and acellular pertussis (DTaP)? birth, 2 months, 6 months, 15 to 18 months, and 10 to 12 years 1 month, 2 months, 6 months, 15 to 18 months, and 4 to 6 years 2 months, 4 months, 6 months, 18 months, 4 to 6 years, and grade 9 birth, 3 months, 6 months, 12 months, and 4 to 6 years

2 months, 4 months, 6 months, 18 months, 4 to 6 years, and grade 9

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.

Allow the infant to rest before feeding.

The nurse assesses an 8-month-old infant for a possible head injury after a fall of about 3 feet. The child is awake, alert, and crying. Vital signs are within normal limits. What action should the nurse take next? Apply 100% supplemental oxygen. Interview the parents about the fall. Assess the infant's pupillary responses. Obtain immediate intravenous access.

Assess the infant's pupillary responses.

When assessing a 2-month-old infant, the nurse feels a "click" when abducting the infant's left hip. What should the nurse do next? Document the finding as normal for a 2-month-old. Check the lengths of the femurs to determine if they are equal. Instruct the mother to keep the leg in an adducted position. Reschedule the child for a follow-up assessment in 3 weeks.

Check the lengths of the femurs to determine if they are equal.

The breastfeeding mother of a 1-month-old diagnosed with cow's milk sensitivity asks the nurse what she should do about feeding her infant. Which recommendation would be most appropriate? Continue to breastfeed, but eliminate all milk products from your own diet. Discontinue breastfeeding, and start using a predigested formula. Limit breastfeeding to once per day, and begin feeding an iron-fortified formula. Change to a soy-based formula exclusively, and begin solid foods.

Continue to breastfeed, but eliminate all milk products from your own diet.

Which action should the nurse include when developing the plan of care for a neonate prior to surgical repair of a myelomeningocele? Apply thin layers of tincture of benzoin around the defect. Position the neonate on the side. Cover the defect with moist, sterile saline dressings. Leave the defect exposed to air.

Cover the defect with moist, sterile saline dressings.

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.

Do nothing because this is a normal finding in a child this age.

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

Examine the fontanels and sutures.

After teaching the parents of an infant with clubfoot requiring application of a plaster cast how to care for the cast, which statement would indicate that the parents have understood the teaching? "If the cast becomes soiled, we will clean it with soap and water." "We will elevate the leg with the cast on pillows, so the leg is above heart level." "We will check the color and temperature of the toes of the casted leg frequently." "The petals on the edge of the cast can be removed after the first 24 hours."

"We will check the color and temperature of the toes of the casted leg frequently."

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

esophageal stricture

Which assessment should be the priority for an infant who has had surgery to correct an intussusception and is now at risk for development of a paralytic ileus postoperatively? measurement of urine specific gravity auscultation of bowel sounds inspection of the first stool passed measurement of gastric output

auscultation of bowel sounds

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

"Babies need comforting and cuddling; meeting these needs will not spoil him."

An infant's death is deemed due to sudden infant death syndrome (SIDS). The parents want to know the cause of SIDS and if they could have done something to prevent it. What explanation should the nurse provide these parents? "SIDS occurs in babies who sleep on their abdomen." "SIDS occurs after an upper respiratory infections." "SIDS occurs only in premature infants." "Unfortunately the cause of SIDS is unknown."

"Unfortunately the cause of SIDS is unknown."

A dehydrated infant is receiving IV therapy. The parent tells the nurse about wanting to hold the infant but being afraid this might cause the IV line to become dislodged. How should the nurse respond? Encourage the parent to interact with the infant while lying in the bed. Provide a comfortable chair for the parent to hold the infant while connected to the IV. Temporarily disconnect the IV line so the parent can hold the child comfortably. Place a restraint on the arm with the IV site so it cannot move or become dislodged.

Provide a comfortable chair for the parent to hold the infant while connected to the IV.

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

Perform a neurologic assessment.

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? head down and lower than the trunk head up and raised above the trunk head to one side and even with the trunk lower than the head head parallel to the nurse and supported at the buttocks

head down and lower than the trunk

The mother of an infant with hemophilia tells the nurse that she is planning to do home teaching when the child reaches school age. She does not want her child in school because the teacher will not watch the child as well as she would. The mother's comments represent what common parental reaction to a child's chronic illness? overprotection devotion mistrust insecurity

overprotection

An infant requires tracheal suctioning after the nurse assesses airway congestion. Which is the priority initial action when performing the procedure? oxygenation prior to the procedure instilling saline solution inserting a suction catheter to the appropriate length donning clean gloves

oxygenation prior to the procedure

A nurse is conducting an infant nutrition class for parents. The nurse should instruct the parents to introduce which foods during the first year of life? Select all that apply. toast with butter and honey pureed fruits cow's milk oatmeal cereal strained vegetables fruit juice

pureed fruits oatmeal cereal strained vegetables

The nurse needs to assess an infant's height to determine if the infant is meeting appropriate growth and development parameters. To obtain the most accurate measurement of an infant's height (length), the nurse measures the: recumbent height with the infant lying on the side. recumbent height with the infant supine. recumbent height with the infant prone. standing height with the infant held upright.

recumbent height with the infant supine.

Which food would be appropriate for a 12-month-old child with celiac disease? oatmeal pancakes rice cereal waffles

rice cereal

What liquid does the nurse recommend the parents of a 1½-month-old infant with hypothyroidism use to administer levothyroxine with? large amount of water milk or orange juice small amount of formula or breast milk infant's bowl of cereal

small amount of formula or breast milk

The nurse gives anticipatory guidance to the parents of a 5-month-old infant about toy safety. What toys should the nurse recommend? plastic toy cars wooden puzzles stuffed animals soft, washable toys

soft, washable toys

Which finding indicates that the infant has adequately evacuated the barium after undergoing a barium enema? absence of fecal mass in the lower abdomen stools that progress from clay-colored to brown bowel sounds of 30 per minute stool guaiac that is negative

stools that progress from clay-colored to brown

A 2-month-old infant is seen in the emergency department for symptoms of infection. The healthcare provider has prescribed an antibiotic via the IM route. In which location should the nurse administer the injection? deltoid dorsogluteal ventrogluteal vastus lateralis

vastus lateralis

The nurse has a prescription to administer an IM injection to a neonate. Which injection site should the nurse select? deltoid dorsogluteal ventrogluteal vastus lateralis

vastus lateralis

The parent of an 11-month-old infant reports to the nurse that the infant sleeps much less than other children. The parent asks the nurse whether the infant is getting sufficient sleep. What should be the nurse's initial response? Reassure the parent that each infant's sleep needs are individual. Ask the parent for more information about the infant's sleep patterns. Instruct the parent to decrease the infant's daytime sleep to increase nighttime sleep. Inform the parent that the infant's growth and development are age-appropriate, so sleep isn't a concern.

Ask the parent for more information about the infant's sleep patterns.

A normal, healthy 2-month old infant is brought to the clinic for the first diphtheria, tetanus, and acellular pertussis (DTaP) immunization. Which route is appropriate to administer this vaccine? oral IM subcutaneous intradermal

IM

When teaching a group of parents about the potential for febrile seizures in children, which information should the nurse include? The exact cause is known. The seizures occur as the fever rises. Children older than age 3 years are most at risk. These seizures commonly occur after immunization administration.

The seizures occur as the fever rises.

When administering an oral medication to an infant, the nurse should take which action to decrease the risk of aspiration? Use an oral syringe to place the medication beside the tongue, and administer the medication as quickly as possible. Place the medication in the infant's bottle of formula and encourage the infant to suck. Keep the infant upright, gently pinch the child's nostrils to encourage the infant's mouth to open, then administer the medication slowly. Use an oral syringe to place the medication beside the tongue, and administer the medication slowly.

Use an oral syringe to place the medication beside the tongue, and administer the medication slowly.

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? stand momentarily without holding onto furniture stand alone well for long periods of time stoop to recover an object on the ground sit without support for long periods of time

sit without support for long periods of time

Parents bring their infant to the clinic, seeking treatment for vomiting and diarrhea that has lasted for 2 days. On assessment, the nurse detects dry mucous membranes and lethargy. What other finding suggests a fluid volume deficit? sunken fontanel decreased pulse rate increased blood pressure low urine specific gravity

sunken fontanel