Passpoint: Infant

Before a routine checkup in the pediatrician's office, an 8-month-old infant sits contentedly on the mother's lap, chewing on a toy. When preparing to examine this infant, what should the nurse plan to do first? Weigh the child. Auscultate the heart and lungs. Measure the head circumference. Elicit the pupillary reaction.

Auscultate the heart and lungs. Heart and lung auscultation rarely distresses an infant, so it should be done early in data collection. Placing a tape measure on the infant's head, shining a light in the eyes, or undressing the infant before weighing may cause distress, making the rest of the examination more difficult.

The parent of a 6-month-old infant with atopic dermatitis asks for advice on bathing the child. Which instructions or information should the nurse give to the parent? Bathe the infant twice daily. The frequency of the infant's baths isn't important in atopic dermatitis. Bathe the infant every other day. Use bubble baths to decrease itching.

Bathe the infant every other day. Bathing removes lipoprotein complexes that hold water in the stratum corneum and increases water loss. Decreasing bathing to every other day can help prevent the removal of lipoprotein complexes. Soap and bubble bath should be used sparingly while bathing the child.

Which intervention by the nurse would be most helpful when discussing hypospadias with the parents of an infant with this defect? Notify the health care provider, and have him talk to the parents. Be there to listen to the parents' concerns. Refer the parents to a counselor. Suggest a support group of other parents who have gone through this experience.

Be there to listen to the parents' concerns. The nurse must recognize that parents are going to grieve the loss of the normal child when they have a neonate born with a birth defect. Initially, the parents need to have a nurse who will listen to their concerns for their neonate's health. Suggesting a support group or referring the parents to a counselor might be helpful, but not initially. The health care provider will need to spend time with the parents to discuss surgery, but the nurse is in the best position to allow the parents to vent their grief and anger initially.

A nurse is feeding a child with a cleft palate. Which nursing action would be a priority? Feed the infant at scheduled times. Limit the amount the infant eats. Remove the nipple if the infant is making loud noises. Burp the infant often.

Burp the infant often. Infants with cleft lip and palate have a tendency to swallow an excessive amount of air, so they need burping often. The amount of formula they eat at each feeding is the same as an infant without cleft lip or palate, and scheduled feedings are not necessary. Loud noises are common when these infants eat.

A physical therapist has instructed the nursing staff in range-of-motion exercises for an infant with torticollis. Which intervention should the nurses perform if they feel uncomfortable performing stretches that result in the infant's crying and grimacing? Call the primary health care provider. Call the physical therapist. Discontinue the exercises. Check the primary health care provider's orders.

Call the physical therapist. The only cure for the torticollis is exercise or surgery. The physical therapist is the expert in exercise and should be called for assistance in this situation. The primary health care provider would be called only if there was concern over the orders written or an abnormal development in the child.

The skin in the diaper area of a 6-month-old infant is excoriated and red. Which instructions would the nurse give to the parent? Change the diaper more often. Decrease the infant's fluid intake to decrease saturating diaper. Wash the area vigorously with each diaper change. Apply talcum powder with diaper changes.

Change the diaper more often. Simply decreasing the amount of time the skin comes in contact with wet, soiled diapers will help heal the irritation. Talc is contraindicated in children because of the risks associated with inhalation of the fine powder. Gentle cleaning of the irritated skin should be encouraged. Infants shouldn't have fluid intake restrictions.

A baby boy has just had surgery to repair his cleft lip. Which nursing intervention is the most important during the immediate postoperative period? Clean the suture line carefully with a sterile solution after every feeding. Give the baby a pacifier to suck for comfort. Allow the infant to cry to promote lung re-expansion. Lay the infant on his abdomen to help drain fluids from his mouth.

Clean the suture line carefully with a sterile solution after every feeding. 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 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.

The nurse observes small white nodules on the roof of an infant's mouth. Which term will the nurse use when describing this finding to the health care provider? milia erythema toxicum melasma Epstein pearls

Epstein pearls Epstein pearls are small white nodules that appear on the roof of a newborn's mouth. Melasma is a dark coloration of the skin seen in pregnant females. Milia are small white bumps that occur on the nose due to clogged sebaceous glands. Erythema toxicum is a maculopapular rash seen in newborns.

The nurse caring for an infant with pyloric stenosis should be alert for which classic sign or symptom? loss of appetite excessive drooling projectile vomiting chronic diarrhea

projectile vomiting The obstruction seen in pyloric stenosis doesn't allow food to pass through to the duodenum. The classic sign of projectile vomiting occurs when the stomach becomes full, and the infant vomits for relief. Drooling would not be a finding in a child with pyloric stenosis but rather in a child with tracheoesophageal fistula. Chronic hunger is commonly seen. There's no diarrhea because food doesn't pass the stomach.

Which developmental milestone would the nurse expect an 11-month-old infant to have achieved? turning a doorknob sitting independently walking independently building a tower of four cubes

sitting independently Infants typically sit independently, without support, by age 8 months. Walking independently may be accomplished as late as age 15 months and still be within the normal range. Few infants walk independently by age 11 months. Building a tower of three or four blocks is a milestone of an 18-month-old. Turning a doorknob is a milestone of a 24-month-old.

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

Allow the infant to rest before feeding. 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.

A 2-month-old infant arrives in the emergency department with a heart rate of 180 beats/minute and a temperature of 103.1° F (39.5° C) rectally. Which intervention is most appropriate? Encourage fluid intake. Give acetaminophen. Apply carotid massage. Place the infant's hands in cold water.

Give acetaminophen. Acetaminophen should be given first to decrease the infant's temperature. A heart rate of 180 beats/minute is normal in an infant with a fever. Fluid intake is encouraged after the acetaminophen is given to help replace insensible fluid losses. Carotid massage is an attempt to decrease the heart rate as a vagal maneuver; it won't work in this infant because the source of the increased heart rate is fever. A tepid sponge bath may be given to help decrease the temperature and calm the infant.

A licensed practical nurse is helping a registered nurse admit an infant with acute gastroenteritis. Which intervention takes priority? Obtaining a stool specimen Offering the infant clear liquids Obtaining a history of the illness Weighing the infant

Obtaining a history of the illness Obtaining a history of the infant's illness is a priority for developing a treatment plan. Getting a stool specimen and weighing the infant can follow taking the history. The nurse shouldn't offer clear liquids because they increase the risk of vomiting, which may worsen the infant's dehydration.

An infant goes into cardiac arrest. When delivering chest compressions as part of cardiopulmonary resuscitation (CPR), where should the rescuer place her fingers? Directly over the xiphoid process One fingerbreadth below the nipple line, directly over the sternum Over the lower third of the sternum Directly over the left nipple

One fingerbreadth below the nipple line, directly over the sternum When delivering chest compressions to an infant, the rescuer should place her fingers one fingerbreadth below the nipple line, directly over the sternum. Compared to the heart of an older child or adult, the infant's heart is higher and more horizontal relative to anatomical landmarks. Placing the fingers over the xiphoid process could cause injury; placing them over the lower third of the sternum or directly over the nipple could make chest compressions ineffective.

The nurse is caring for an infant with congenital clubfoot. After the final cast has been removed, which member of the health care team will most likely help the infant with leg and ankle exercises and provide his parents with a home exercise regimen? Physical therapist Recreational therapist Exercise physiologist Occupational therapist

Physical therapist After the final cast has been removed, foot and ankle exercises may be necessary to improve range of motion. A physical therapist should work with the child. A physical therapist is trained to help clients restore function and mobility, which will prevent further disability. An occupational therapist, who helps the chronically ill or disabled to perform activities of daily living and adapt to limitations, isn't necessary at this time. A recreational therapist, who uses games and group activities to redirect maladaptive energy into appropriate behavior, also isn't required. Exercise physiologists help people devise exercise fitness programs; they don't work with children who have undergone treatment for clubfoot.

A mother brings her 2-month-old infant to the clinic for a well-baby checkup. To best assess the interaction between the mother and infant, the nurse should observe them: as the infant sleeps. as the mother feeds the infant. as the infant plays. as the mother rocks the infant.

as the mother feeds the infant. The nurse can best assess mother-infant interaction during feeding, such as by observing how closely the mother holds the infant and how she looks at the infant's face. These behaviors help reveal the mother's anxiety level and overall feelings for the infant. The infant's posture and response during feeding provide clues to the infant's comfort level and feelings. Sleeping doesn't provide an opportunity for mother-infant interaction. Although playing and rocking may provide clues about mother-infant interaction, they aren't the best activities to assess. During playing, for instance, the mother may interact with the infant at a distance. Rocking promotes closeness but not interaction; the mother can rock the infant while talking to someone else or staring off into the distance.

An 8-month-old infant has been diagnosed with developmental dysplasia of the hip (DDH). What is the most significant finding the nurse would expect in the perinatal history related to DDH? breech presentation at birth mother's exercise routine during the third trimester Apgar score of 4 at 1 minute and 6 at 5 minutes serum calcium level at birth

breech presentation at birth Breech presentation is commonly associated with DDH. The mother's exercise routine during the third trimester, serum calcium level at birth, and an Apgar score of 4 at 1 minute and 6 at 5 minutes have no relation to hip dysplasia.

If an infant's I.V. access site is in an extremity, the nurse should: restrain all four extremities. restrain the extremity to the bed's side rail. use a padded board to secure the extremity. allow the extremity to be loose.

use a padded board to secure the extremity. A padded board is adequate to secure the extremity. Restraining all four extremities can be harmful and uncomfortable for the child. Restraining the extremity to the bed's side rail limits the child's movement; the child may bang against the rail and cause injury. Allowing the extremity to be loose increases the risk that the I.V. will infiltrate or be dislodged by the infant.

The nurse is to administer IV fluids to an infant. Which safeguard would be most important for the nurse to use? use of a gravity infusion set with a filter use of an intravenous infusion pump use of a micro drop (mini drip) infusion set administering fluid at slowest rate by infant weight

use of an intravenous infusion pump Use of an infusion pump to regulate the flow rate is the appropriate safeguard because infants and children are particularly vulnerable to IV fluid overload. Using a gravity infusion set or a micro drop infusion set does not permit sufficiently accurate flow to protect against fluid overload. Administering fluid at the slowest possible rate may not benefit the infant.

Which precaution should a nurse caring for a 2-month-old infant with respiratory syncytial virus (RSV) take to prevent the spread of infection? no precautions are required; the virus isn't contagious proper hand washing between clients only wear gown, gloves, and mask wear gloves only

wear gown, gloves, and mask RSV is highly contagious and is spread through direct contact with infectious secretions via hands, droplets, and fomites. Gown, gloves, and mask should be worn for care of the infant to prevent the spread of infection, in addition to proper hand washing between clients.

The nurse is preparing the parents of an infant with hypospadias for surgery. Which statement made by the parents would indicate the need for further education? "After surgery, my infant's penis will look perfectly normal." "Surgical repair may need to be performed in several stages." "My infant will probably be in some pain after the surgery and might need to take some medication for relief." "Skin grafting might be involved in my infant's repair."

"After surgery, my infant's penis will look perfectly normal." It's important to stress to the parents that even after a repair of hypospadias the outcome isn't a completely "normal-looking" penis. The goals of surgery are to allow the child to void from the tip of his penis, void with a straight stream, and stand up while voiding.

The nurse is reinforcing education with parents about therapeutic management of their neonate diagnosed with congenital hypothyroidism. Which response by a parent would indicate the need for further education? "Treatment should begin as soon as possible after diagnosis is made." "As my baby grows, his thyroid gland will mature and he won't need medications." "Treatment involves lifelong thyroid hormone replacement therapy." "My baby will need regular measurements of his thyroxine levels."

"As my baby grows, his thyroid gland will mature and he won't need medications." Treatment involves lifelong thyroid hormone replacement therapy that begins as soon as possible after diagnosis. The goal of treatment is to abolish all signs of hypothyroidism and to reestablish normal physical and mental development. The drug of choice is synthetic levothyroxine. Regular measurements of thyroxine levels are important in ensuring optimal treatment.

The parents of an 11-month-old are concerned because the frequency of their infant's bowel movements has decreased from three to four each day to one to two each day. Which response by the nurse is best? "By age 11 months, most infants have one to two bowel movements per day." "You should increase the amount of fruit in your infant's diet." "You should increase the amount of water you give to your baby." "The pediatrician might order a barium enema to make sure your baby doesn't have Hirschsprung's disease."

"By age 11 months, most infants have one to two bowel movements per day." The nurse should respond by telling the parents that it's normal for an 11- month-old to have one to two bowel movements per day. A child with Hirschsprung's disease has difficulty moving his bowels at all. The infant doesn't require more fruit or water in his diet.

A nurse is caring for a neonate who has hypospadias. His parents are asking about having the baby circumcised before discharge. When reinforcing education with the parents about their child's condition, what should the nurse tell them? "Circumcision is delayed as the foreskin is needed for surgical correction. "Circumcision is necessary because the foreskin obstructs the urethral meatus." "Circumcision will correct the hypospadias allowing normal urination. "The baby can still be circumcised as planned."

"Circumcision is delayed as the foreskin is needed for surgical correction. Circumcision is the surgical removal of the foreskin of the penis. In hypospadias, the urethral meatus is on the underside of the penis. A neonate with hypospadias should not be circumcised because the surgeon may need the foreskin for surgical repair. The foreskin does not block the urethral meatus, which may be located near the glans, along the underside of the penis, or at the base. Circumcision does not correct hypospadias because the location of the urethral meatus is not changed during circumcision.

A mother is concerned that she might be spoiling her 2-month-old daughter by picking her up each time she cries. Which suggestion should the nurse offer? "Leave your baby alone for 10 minutes. If she hasn't stopped crying by then, pick her up." "Crying at this age indicates hunger. Try feeding her when she cries." "Continue to pick her up when she cries because young infants need cuddling and holding to meet their needs." "If the baby's diaper is dry when she's crying, leave her alone and she'll fall asleep."

"Continue to pick her up when she cries because young infants need cuddling and holding to meet their needs." The nurse should advise the mother to continue to pick the infant up when she cries because a young infant needs to be cuddled and held when crying. Because the infant's cognitive development isn't advanced enough for her to associate crying with getting attention, it would be difficult to spoil her at this age. Even if her diaper is dry, a gentle touch may be necessary until she falls asleep. Crying for 10 minutes wears an infant out; ignoring crying can make the infant mistrust caregivers and the environment. Infants cry for many reasons, not just when hungry.

The 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? "I know that this disease is serious and can lead to asthma." "I'm so afraid for my baby's life because so many infants die from this illness." "My baby needs to be cured this time so it won't happen again." "I hope my baby will come home from the hospital."

"I know that this disease is serious and can lead to asthma." Bronchiolitis places the child at risk for developing asthma. If diagnosed and treated promptly, most infants recover from the illness and return home. Infants typically don't have recurrences of bronchiolitis.

When reinforcing education with parents of an infant newly diagnosed with diabetes insipidus, which statement by the parent indicates an appropriate understanding of this condition? "When my infant stabilizes, I won't have to worry about giving hormone medication." "I don't have to measure the amount of fluid intake that I give my infant." "My infant will outgrow this condition." "I realize that treatment for diabetes insipidus is lifelong."

"I realize that treatment for diabetes insipidus is lifelong." Diabetes insipidus requires lifelong treatment. The amount of fluid intake is important and must be measured with the infant's output to monitor the medication regimen. The infant won't outgrow this condition.

A bottle-fed infant, age 3 months, is brought to the pediatrician's office for a well-child visit. During the previous visit, the nurse taught the mother about infant nutritional needs. Which statement by the mother during the current visit indicates effective teaching? "I started the baby on cereals and fruits because he wasn't sleeping through the night." "I'm giving the baby skim milk because he was getting so chubby." "I'm giving the baby iron-fortified formula and a fluoride supplement because our water isn't fluoridated." "I started putting cereal in the bottle with formula because the baby kept spitting it out."

"I'm giving the baby iron-fortified formula and a fluoride supplement because our water isn't fluoridated." Iron-fortified formula supplies all the nutrients an infant needs during the first 6 months; however, fluoride supplementation is necessary if the local water supply isn't fluoridated. Before age 6 months, solid foods, such as cereals, aren't recommended because the GI tract tolerates them poorly. Also, a strong extrusion reflex causes the infant to push food out of the mouth. Mixing solid foods in a bottle with liquids deprives the infant of experiencing new tastes and textures and may interfere with development of proper chewing. Skim milk doesn't provide sufficient fat for an infant's growth.

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? "Immunizations will have to be delayed until the casts come off." "We will have to be careful how we hold our baby." "We'll have to bring our baby back every week or two for cast changes." "I know I will have to be careful when changing his diapers."

"Immunizations will have to be delayed until the casts come off." 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.

The mother of a 3-day-old, breast-fed infant expresses concern that her infant has had two recent diapers that contained a lot of loose, yellowish stool. Which explanation by the nurse is best? "New parents tend to worry too much. Infants have frequent stools." "It's normal for breast-fed infants to pass three or more loose, yellow stools per day." "Please save the next diaper so the nurses can examine the stools." "Eliminating dairy products from your diet can help clear this up."

"It's normal for breast-fed infants to pass three or more loose, yellow stools per day." Infants usually pass two to three stools daily — more if they're breast-fed. By day 4, the stool of the bottle-fed infant is pasty and pungent; breast-fed infants have stools that are sweet-smelling, loose, and yellow. It isn't necessary for the mother to save the diaper to allow the nurses to assess the stool. Stating that new parents tend to worry too much is condescending. The mother should be instructed to report frequent, watery stools. Eliminating dairy products from the mother's diet won't change the quality of the infant's stools.

A parent brings her 3-month-old to the clinic for a well-baby examination. Which statement by the parent should concern the nurse? "She's eating rice cereal and applesauce." "She spits up a small amount after each feeding." "She drinks 6 oz of iron-fortified formula every 4 to 5 hours." "She loves to be cuddled during and after her feedings."

"She's eating rice cereal and applesauce." The nurse should be concerned when the mother tells her that the 3-month- old is eating rice cereal and applesauce. A 3-month-old doesn't have the ability to push the food to the back of the throat and then swallow it, thereby increasing the risk of aspiration. Food allergies are also likely when solid foods are introduced at an early age. Spitting up a small amount is normal for an infant this age. The infant should be drinking 6 oz every 4 to 5 hours, and she should be held and cuddled during and after feedings.

After explaining the causes of hypothyroidism to the parents of a newly diagnosed infant, the nurse should recognize that education needs to be reinforced when which question is asked? "Do you mean that hypothyroidism may be caused by a problem in the way the body makes thyroxine?" "Are you saying that hypothyroidism is caused by a problem in the way the thyroid gland develops?" "So, hypothyroidism can be treated by exposing our baby to a special light, right?" "So, hypothyroidism can be only temporary, right?"

"So, hypothyroidism can be treated by exposing our baby to a special light, right?" Congenital hypothyroidism can be permanent or transient and may result from a defective thyroid gland or an enzymatic defect in thyroxine synthesis. Phototherapy is not used to treat physiologic jaundice and indicates that the parents need more information.

The parent of a 4-month-old infant asks about the strawberry hemangioma on the cheek. Which statement would the nurse include when responding to the parent? "The lesion will continue to grow for 3 years, then need surgical removal." "If the lesion continues to enlarge, referral to a pediatric oncologist is warranted." "The lesion will continue to grow until age 12 months, then begin to resolve by age 2 to 3 years." "Surgery is indicated before age 12 months if the diameter of the lesion is greater than 3 cm."

"The lesion will continue to grow until age 12 months, then begin to resolve by age 2 to 3 years." Hemangiomas are rapidly growing vascular lesions that reach maximum growth by age 1 year. The growth period is then followed by an involution period of 6 to 12 months. Lesions show complete involution by age 2 or 3 years. These benign lesions don't need surgical or oncologic referrals.

A nurse is reinforcing education with parents about the nutritional needs of their full-term infant, age 2 months, who is breastfeeding. Which response shows that the parents understand their infant's dietary needs? "We should add new fruits to the diet one at a time." "We won't start any solid foods now." "We'll introduce cereal into the diet now." "We'll start the baby on skim milk."

"We won't start any solid foods now." Because breast milk provides all of the nutrients that a full-term infant needs for the first 6 months, the parents should not introduce solid foods into the infant's diet at this time. Before age 6 months, an infant's GI tract cannot tolerate solid foods such as vegetables and fruit. Cereal may be introduced at 4 to 6 months of age. Parents should not provide skim milk to a child younger than age 2 because it does not have sufficient fat for infant growth.

The nurse is teaching parents how to select appropriate toys for their 10-month-old infant. Which statement by the parents indicates effective teaching? "We'll get a mobile to place over the baby's crib." "We'll get a push toy for the baby." "We'll get a mirror to hang on the baby's crib." "We'll get a rattle for the baby to play with."

"We'll get a push toy for the baby." At age 10 months, a push toy promotes development of an infant's gross and fine motor skills and aids cognitive development. A mobile provides appropriate visual stimulation for an infant up to age 4 months; after this age, a mobile may pose a danger to an infant. Rattles promote gross and fine motor abilities in infants ages 4 to 8 months. The type of mirror needs to be investigated because one that isn't made especially for an infant could cause harm.

A mother and grandmother bring a 3-month-old infant to the well-baby clinic for a routine checkup. As the nurse weighs the infant, the grandmother asks, "Shouldn't the baby start eating solid food? My kids started on cereal when they were 2 weeks old." Which response by the nurse would be appropriate? "The baby is gaining weight and doing well. There is no need for solid food yet." "Things have changed a lot since your children were born." "We've found that babies can't digest solid food properly until they're 4 months old." "We've learned that introducing solid food early leads to eating disorders later in life."

"We've found that babies can't digest solid food properly until they're 4 months old." Infants younger than 4 months lack the enzymes needed to digest complex carbohydrates. Option 1 doesn't address the grandmother's question directly. Option 2 is a cliché that may block further communication with the grandmother. Option 4 is incorrect because no evidence suggests that introducing solid food early causes eating disorders.

The nurse is approached by the mother of a child with hypospadias. She says to the nurse, "Why did this have to happen to my baby? Why couldn't he be perfect? How could this have happened?" What should the nurse say in response? "Don't worry. After surgical repair you'll hardly remember there was anything wrong with your baby." "This is only a minor problem. Many other babies are born with worse defects." "I'll ask the physician to explain to you how this defect occurs." "You seem upset. Tell me about it."

"You seem upset. Tell me about it." By verbalizing observations of the client's behavior, the nurse acknowledges the client's feelings. By listening, the nurse can help the client understand her feelings and begin to deal with them. Telling the client that there are babies with worse defects doesn't acknowledge — and may even belittle — her feelings. Providing a stock answer, such as "Don't worry," shows a lack of interest in the client's feelings. Offering to ask the physician also doesn't address the client's feelings.

Sudden infant death syndrome (SIDS) is one of the most common causes of death in infants. At what age is SIDS most likely to occur? 6 months to 1 year, peaking at 10 months 6 to 8 weeks 1 week to 1 year, peaking at 2 to 4 months 1 to 2 years

1 week to 1 year, peaking at 2 to 4 months SIDS can occur anytime between ages 1 week and 1 year. The incidence peaks at ages 2 to 4 months.

The nurse is caring for an infant diagnosed with thrush. Which instruction should the nurse give to a client's mother who will be administering nystatin oral solution? Administer half the dose before and half after a feeding. Mix the drug with small amounts of formula in bottle. Administer the drug right before meals by using a gauze pad. Administer the drug right after meals by swabbing the mouth.

Administer the drug right after meals by swabbing the mouth. Nystatin oral solution is an antifungal medication used to treat fungal or yeast infections. Nystatin oral solution should be swished around the mouth after eating for the best contact with mucous membranes. Taking the drug before or with meals does not allow for optimal contact with mucous membranes.

When preparing to feed an infant with pyloric stenosis, which intervention should the nurse give highest priority? Burp the infant frequently. Discourage parental participation. Discontinue feedings if the infant vomits. Give feedings quickly.

Burp the infant frequently. Infants with pyloric stenosis usually swallow a lot of air from sucking on their hands and fingers because of their intense hunger (feedings aren't easily tolerated). Burping often lessens gastric distention and increases the likelihood the infant will retain the feeding. Feedings are given slowly with the infant lying in a semi-upright position. Parental participation should be encouraged and allowed to the extent possible. Record the type, amount, and character of the vomit as well as its relation to the feeding. The amount of feeding volume lost is usually refed.

How should a nurse position an infant when administering an oral medication? Held on the nurse's lap Seated in a high chair Held in the bottle- or breast-feeding position Restrained flat in the crib

Held in the bottle- or breast-feeding position A nurse should hold an infant in the bottle- or breast-feeding position when administering an oral medication by placing the child's inner arm behind his back, supporting his head in the crook of the elbow, and holding the child's free hand with the hand of the supporting arm. An infant shouldn't sit unsupported in a high chair. Administering medication to an infant lying flat could cause choking and aspiration. Holding the infant in the lap doesn't prevent the infant's arms from moving around, which may cause the medicine to spill.

A 2-month-old infant is brought to the well-baby clinic for a first checkup. On initial measurements, the nurse notes the infant's head circumference is at the 95th percentile. Which action would the nurse take first? Measure the head again. Obtain vital signs. Notify the primary health care provider. Observe neurologic signs.

Measure the head again. Whenever there's a question about vital signs or assessment data, the first logical step is to reassess and determine if an error has been made initially. In this case, measuring the head again would be the priority. Notifying the primary health care provider and assessing neurologic and vital signs are important and would follow the head reassessment, if warranted.

Which sexually transmitted disease is preventable through infant vaccination? Chlamydia Syphilis Hepatitis B Gonorrhea

Hepatitis B The hepatitis B vaccine is given by the I.M. route at birth or before hospital discharge, at ages 1 to 4 months, and again at ages 6 to 18 months for a total of three doses. Vaccines aren't currently available to prevent syphilis, gonorrhea, or chlamydia.

Which nursing intervention is essential in the care of an infant with cleft lip and palate? Hold the infant flat while feeding. Use a normal nursery nipple for feedings. Involve the parents in the infant's care. Discourage breast-feeding.

Involve the parents in the infant's care. The sooner the parents become involved, the quicker they can determine the method of feeding best suited for them and the infant. Breast-feeding, like bottle-feeding, may be difficult but can be facilitated if the mother intends to breast-feed. Sometimes, especially if the cleft is not severe, breast-feeding may be easier because the human nipple conforms to the shape of the infant's mouth. Feedings are usually given in the upright position to prevent formula from coming through the nose. Various special nipples have been devised for infants with cleft lip or palate; a normal nursery nipple is not effective.

A mother is discontinuing breast-feeding after 3 months. The nurse should advise her to include which item in her infant's diet? Iron-fortified formula alone Iron-fortified formula and baby food Skim milk and baby food Whole milk and baby food

Iron-fortified formula alone The American Academy of Pediatrics (Canadian Pediatric Society) recommends breast-feeding infants for at least 12 months. When breast-feeding isn't possible, an iron-fortified formula is recommended. By age 6 months, an infant should be mature enough to begin eating iron-fortified cereal mixed with formula or breast milk. The Academy doesn't recommend whole milk before age 12 months or skim milk before age 2 years.

For an 8-month-old infant, which toy promotes cognitive development? A small rubber ball Jack-in-the-box Finger paint A play gym strung across the crib

Jack-in-the-box According to Piaget's theory of cognitive development, an 8-month-old child will look for an object such as a Jack-in-the-box once it disappears from sight to develop the cognitive skill of object permanence. Finger paint and small balls are potentially dangerous because infants frequently put their fingers or objects in their mouths. Anything strung across a crib, such as a play gym, is a safety hazard — especially to a child who may use it to pull up to a standing position.

A nurse is caring for an infant with meningitis. Which nursing action is a priority? Maintain fluid and electrolyte balance. Control seizures. Control hyperthermia. Maintain an adequate airway.

Maintain an adequate airway. Maintaining an adequate airway is always a top priority. Maintaining fluid and electrolyte balance and controlling seizures and hyperthermia are all important, but maintaining an adequate airway takes priority.

An infant is hospitalized for treatment of nonorganic failure to thrive. Which nursing action is most appropriate for this child? Encouraging the infant to hold a bottle Maintaining a consistent, structured environment Keeping the infant on bed rest to conserve energy Rotating caregivers to provide more stimulation

Maintaining a consistent, structured environment The nurse caring for an infant with nonorganic failure to thrive should strive to maintain a consistent, structured environment. Encouraging the infant to hold a bottle would reinforce an uncaring feeding environment. The infant should receive social stimulation rather than be confined to bed rest. The number of caregivers should be minimized to promote consistency of care.

A 6-month-old infant with uncorrected tetralogy of Fallot suddenly becomes increasingly cyanotic and diaphoretic, with weak peripheral pulses and an increased respiratory rate. What is the priority action by the nurse? Place the infant in a knee-chest position. Place the infant in Fowler's position. Administer oxygen. Administer morphine sulfate.

Place the infant in a knee-chest position. The knee-chest position reduces the workload of the heart by increasing the blood return to the heart and keeping the blood flow more centralized. Oxygen should be administered quickly but only after placing the infant in the knee-chest position. Morphine should be administered after positioning and oxygen administration are completed. Fowler's position wouldn't improve tetralogy of Fallot.

A recent abduction of a 2-month-old infant has raised awareness of the need for security plans for hospitals. Which security measure helps ensure the hospitalized infant's security? Placing security guards at the infant unit entrances Keeping the doors of the infant unit locked and having visitors call the nurses' station for admission Placing an identification bracelet on the infant and the parent immediately on admission Allowing only the parents to visit with the infant

Placing an identification bracelet on the infant and the parent immediately on admission The safest way to ensure that the parents or legal guardians are who they say they are is to place a bracelet on both the infant and the parents or guardians at the time of admission. Limiting visitors isn't necessary. Locking the door and having visitors call the nurses' station for admission increases the workload of the nursing staff. It isn't feasible to place security guards at the entrances.

To obtain the most accurate measurement of an infant's height (length), the nurse should measure which of the following? Standing height with the infant held upright Recumbent height with the infant lying on the side Recumbent height with the infant supine Recumbent height with the infant prone

Recumbent height with the infant supine For the most accurate measurement, the nurse should place the infant in a supine position and then measure recumbent height. Measuring recumbent height with the infant lying on the side would yield an inaccurate result because the infant's body can't be extended adequately. Measuring recumbent height with the infant prone would yield an inaccurately long result because it includes the length of the foot. Measuring standing height with the infant held upright would yield an inaccurate result until the child no longer needs assistance to stand up straight.

The nurse is caring for an infant who has undergone a surgical repair of a cleft lip. The health care provider prescribes elbow restraints. What nursing action should be included in the infant's plan of care? Keep the restraints on one arm at a time. Remove the restraints every 2 hours. Remove the restraints while the infant is asleep. Use the restraints until the infant fully recovers from anesthesia.

Remove the restraints every 2 hours. The nurse should remove one elbow restraint at a time every 2 hours for about 5 minutes to allow exercise of the arms and to inspect the infant for skin irritation. To prevent the infant from touching and disrupting the suture line, the nurse should use the restraints when the infant is asleep and awake. Both arms should be restrained to be effective. The nurse should maintain the elbow restraints from the time the infant recovers from anesthesia until the suture line is healed.

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

Report the suspicion to the health care provider. 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. 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.

During a well-baby visit, a mother asks the nurse about starting her infant on solid foods. The nurse should instruct her to introduce which solid food first? Applesauce Egg whites Rice cereal Yogurt

Rice cereal Rice cereal is the first solid food an infant should receive because it's easy to digest and is associated with few allergies. Next, the infant can receive pureed fruits, such as bananas, applesauce, and pears, followed by pureed vegetables, egg yolks, cheese, yogurt, and, finally, meat. Egg whites shouldn't be given until age 9 months because they may trigger a food allergy.

While preparing to discharge a 9-month-old infant who's recovering from gastroenteritis and dehydration, the nurse teaches the parents about their infant's dietary and fluid requirements. The nurse should include which other topic in the teaching session? Toilet training Nursery schools Safety guidelines Preparation for surgery

Safety guidelines The nurse always should reinforce safety guidelines when teaching parents how to care for their child. By giving anticipatory guidance, the nurse can help prevent many accidental injuries. For parents of a 9-month-old infant, it's too early to discuss nursery schools or toilet training. Because surgery isn't used to treat gastroenteritis, this topic is inappropriate.

When talking to the parents of a neonate with congenital hypothyroidism, the nurse should encourage which action? Seek professional genetic counseling. Talk to relatives who have gone through a similar experience. Retrace the family tree for others born with this condition. Wait until the neonate is 1 year of age before obtaining counseling.

Seek professional genetic counseling. Seeking professional genetic counseling is the best option for parents who have a neonate with a genetic disorder, such as congenital hypothyroidism. Retracing the family tree and talking to relatives will not help the parents become better educated about the disorder. Education about the disorder should occur as soon as the parents are ready, so they will understand the genetic implications for future children.

An infant, diagnosed with bronchiolitis, is ordered a mist tent with oxygen. The parents question how a mist tent with oxygen can help their infant. The nurse is most correct to identify which? Select all that apply. assists in improving oxygen saturation assists in drying secretions assists in improving cough assists in improving swallowing assists in decreasing bronchial edema

assists in decreasing bronchial edema; assists in improving cough; assists in improving oxygen saturation The nurse is correct to identify that a mist tent with oxygen assists with decreasing bronchial edema by soothing the respiratory tract. The tent improves the mechanism of cough. Improving ventilator processes improves oxygen saturation. The mist tent with oxygen hydrates, not dries, secretions. The mist tent does not improve swallowing function.

The nurse is collecting data on an 8-month-old infant during a wellness checkup. Which of the following is a normal developmental task for an infant this age? Saying two words Sitting without support Playing patty-cake Feeding himself with a spoon

Sitting without support According to the Denver Developmental Screening Test, most infants should be able to sit unsupported by age 7 months. A 15-month-old child should be able to say two words. By 17 months, the toddler should be able to feed himself with a spoon. A 10-month-old infant should be able to play patty-cake.

An 11-month-old infant with bronchopulmonary dysplasia and a tracheostomy experiences a decline in oxygen saturation from 97% to 88%. The infant appears anxious and the heart rate is 180 beats/minute. Which intervention is most appropriate? Change the tracheostomy tube. Increase the oxygen flow rate. Obtain an arterial blood gas (ABG) level. Suction the tracheostomy tube.

Suction the tracheostomy tube. Tracheostomy tubes, particularly in small children, require frequent suctioning to remove mucus plugs and excessive secretions. The tracheostomy tube can be changed if suctioning is unsuccessful. Obtaining an ABG level may be beneficial if oxygen saturation remains low and the child appears to be in respiratory distress. Increasing the oxygen flow rate will only help if the airway is patent.

The nurse is gathering data for an infant experiencing a sickle cell crisis. Which finding by the nurse is most significant to determine the state of hydration? The infant participates in exercise. The infant maintains bladder control. The infant has normal skin turgor. The infant has no bruises.

The infant has normal skin turgor. Normal skin turgor indicates the infant isn't severely dehydrated. Dehydration may cause sickle cell crisis or worsen a crisis. Bruising isn't associated with sickle cell crisis. Bed rest is preferable during a sickle cell crisis. Bladder control may be lost when oral or IV fluid intake is increased during a sickle cell crisis.

A nurse is reinforcing education for parents of an infant with congenital hypothyroidism. Which statement should be included? A large goiter in a neonate does not present a problem. The severity of the disorder depends on the amount of thyroid tissue present. Usually, the neonate exhibits obvious signs of hypothyroidism. Preterm neonates usually are not affected by hypothyroidism.

The severity of the disorder depends on the amount of thyroid tissue present. The severity of hypothyroidism depends on the amount of thyroid tissue present. The more thyroid tissue present, the less severe the disorder. Usually, the neonate does not exhibit obvious signs of the disorder because of maternal circulation. A large goiter in a neonate could possibly occlude the airway and lead to obstruction. Preterm neonates are usually affected by hypothyroidism as a result of hypothalamic and pituitary immaturity.

A neonate is recovering from surgery to repair a cleft lip. What should the nurse do to prevent trauma to the suture line? Administer foods at the front of the mouth. Use a bulb syringe with a rubber tip for feedings. Place the infant in a prone position after feeding. Use a straw for feedings.

Use a bulb syringe with a rubber tip for feedings. A bulb syringe with a rubber tip is a safe, effective feeding device for a neonate who has undergone surgery to repair a cleft lip. Foods should be administered at the side of the mouth, not at the front, to prevent trauma to the suture line. A straw should never be used for feedings. The infant should be placed on his right side after feeding to prevent aspiration. The infant shouldn't be placed prone because this position places pressure on the suture line.

When administering an I.M. injection to an infant, the nurse should use which site? Deltoid Dorsogluteal Vastus lateralis Ventrogluteal

Vastus lateralis The recommended injection site for an infant is the vastus lateralis or rectus femoris muscle. The deltoid is inappropriate. The dorsogluteal and ventrogluteal sites can be used only in toddlers who have been walking for about 1 year.

The nurse must administer a liquid medication to an infant. Which step should the nurse take first? Hold the infant securely in the crook of her arm and raise the infant's head to about a 45-degree angle. Place the dropper at the corner of the infant's mouth so the drug runs into the pocket between the cheek and gum. Identify the infant by checking the armband. Verify the physician's order.

Verify the physician's order. 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. Next, 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 so keeps him from spitting out the drug and reduces the risk of aspiration.

The nurse is preparing to administer pediatric eye drops to a 9 month old. Which of the following interventions would be in the nurse's plan of care? Select all that apply. Wash hands. Massage the eye after instillation. Put on gloves. Have the child sit on the parent's lap. Pull the lower lid down. Place the drop in the conjunctival sac.

Wash hands.; Place the drop in the conjunctival sac; Massage the eye after instillation; Put on gloves; Pull the lower lid down.

The parents of an infant diagnosed with hypothyroidism have been taught to count the infant's pulse. Which intervention should be reinforced in case a high pulse rate is obtained? Allow the infant to take a nap and then give the medication. Give the medication and then consult the health care provider. Withhold the medication and give a double dose the next day. Withhold the medication and call the health care provider.

Withhold the medication and call the health care provider. If parents have been taught to count the pulse of an infant diagnosed with hypothyroidism, they should be instructed to withhold the dose and consult their health care provider if the pulse rate is above a certain value.

Which activity should be recommended for long-term support of parents who have lost an infant due to sudden infant death syndrome (SIDS)? discussing feelings with family and friends attending counseling sessions attending church regularly attending support groups

attending support groups The best support will come from parents who have had the same experience. Attending church and discussing feelings with family and friends can offer support, but they may not understand the experience. Counseling sessions are usually a short-term support.

A 3-month-old infant is admitted to the hospital to rule out nonaccidental trauma. X-ray findings indicate a fractured right humerus, fractured ribs, and a fractured left scapula. In this situation, a nurse is responsible for: reporting the suspicions to the hospital's chief of pediatric services. contacting the infant's next of kin to begin discharge planning. contacting the local children's protective service office with an anonymous tip. ensuring that the suspected child abuse is reported to local authorities.

ensuring that the suspected child abuse is reported to local authorities. Nurses must report suspicions of child abuse to local authorities. The contact procedure may vary among hospitals, but the nurse is responsible for making the report. Reporting suspected abuse to the hospital's chief of pediatric services isn't appropriate. Contacting the infant's next of kin to begin discharge planning is inappropriate because the infant may not be discharged to the next of kin. Providing an anonymous tip isn't appropriate behavior for a professional nurse. The hospital record is important to the legal process, and the nurse must handle it professionally.

The nurse cares for an infant receiving inadequate treatment for congenital hypothyroidism. Which signs or symptoms should the nurse expect to observe? fatigue and sleepiness irritability and jitteriness diarrhea increased appetite

fatigue and sleepiness Signs of inadequate treatment in an infant with congenital hypothyroidism are fatigue, sleepiness, decreased appetite, and constipation.

A family is experiencing the death of an infant from Sudden Infant Death Syndrome (SIDS). What initial reaction does the nurse anticipate the family will exhibit? acceptance of the diagnosis requests for the infant's belongings feelings of blame or guilt questions regarding the etiology of the diagnosis

feelings of blame or guilt During the first few moments, the parents usually are in shock and have overwhelming feelings of blame or guilt. Acceptance of the diagnosis and questions regarding the etiology may not occur until the parents have had time to see the child. The infant's belongings are usually packaged for the family to take home, but some parents may see this as a painful reminder of their deceased child.

Which intervention should be included in the care plan for children with an increased risk of sudden infant death syndrome (SIDS)? pulmonary function testing at regular intervals pulse oximetry while sleeping chest x-ray at age 1 month home apnea monitoring

home apnea monitoring A home apnea monitor is recommended for infants with an increased risk of SIDS. Diagnostic tests, such as pulmonary function tests, pulse oximetry, and chest x-rays, can't diagnose the risk of surviving or dying from SIDS.

Which complications should the nurse be most concerned about in the first 12 hours of life for a neonate born with a myelomeningocele? delayed growth and development impaired physical mobility infection constipation

infection All of these complications are a potential for a child with a myelomeningocele. However, during the first 12 hours of life, the most life-threatening event would be an infection. The other potential complications will be addressed as the child develops.

A 3-month-old infant with meningococcal meningitis has just been admitted to the pediatric unit. Which nursing intervention has the highest priority? obtaining history information from the parents instituting droplet precautions orienting the parents to the pediatric unit administering acetaminophen

instituting droplet precautions Instituting droplet precautions is the priority for a newly admitted infant with meningococcal meningitis. Acetaminophen may be prescribed, but administering it does not take priority over instituting droplet precautions. Obtaining history information and orienting the parents to the unit do not take priority.

A nurse is observing an infant with thyroid hormone deficiency. Which signs would the nurse commonly observe? tachycardia, profuse perspiration, and diarrhea lethargy, feeding difficulties, and constipation hypertonia, small fontanels, and moist skin dermatitis, dry skin, and round face

lethargy, feeding difficulties, and constipation Hypothyroidism results from inadequate thyroid production to meet an infant's needs. Clinical signs include feeding difficulties, prolonged physiologic jaundice, lethargy, and constipation.

Which complications should the nurse be most concerned about in the first 12 hours of life for a neonate born with a myelomeningocele? constipation infection impaired physical mobility delayed growth and development

lethargy, feeding difficulties, and constipation Hypothyroidism results from inadequate thyroid production to meet an infant's needs. Clinical signs include feeding difficulties, prolonged physiologic jaundice, lethargy, and constipation.

Most oral pediatric medications are administered: with meals. ½ hour after meals. on an empty stomach. with the nighttime formula.

on an empty stomach. Most oral pediatric medications are administered on an empty stomach. They aren't usually administered with milk or formula because these can affect gastric pH and alter drug absorption. Because a child's meals usually contain milk or a milk product, the nurse wouldn't administer the drugs with meals or even ½ hour after meals.

An infant's parent gives a history of poor feeding for a few days. The nurse observes white plaques in the infant's mouth with an erythematous base. The plaques stick to the mucous membranes tightly and bleed when scraped. The nurse would suspect which condition? chickenpox measles herpes lesions oral candidiasis

oral candidiasis Oral candidiasis, or thrush, is a painful inflammation that can affect the tongue, soft and hard palates, and buccal mucosa. Chickenpox, or varicella, causes open ulcerations of the mucous membranes. Herpes lesions are usually vesicular ulcerations of the oral mucosa around the lips. Measles that form Koplik spots can be identified as pinpoint, white, elevated lesions.

The parents of a 6 month old diagnosed with a terminal brain tumor have chosen palliative care. Which interventions will be provided for this infant? Select all that apply. pain management and comfort measures curative surgery to remove the tumor chemotherapy and radiation therapy for a possible cure parental support enabling the parents to participate in the infant's care serum blood analysis to monitor cancer levels

pain management and comfort measures; parental support enabling the parents to participate in the infant's care

An infant is examined and found to have a petechial rash. How will the nurse document this finding? a collection of blood from ruptured blood vessels and larger than 1 cm in diameter purple to brown bruises, macular or papular, of various sizes pinpoint, pink to purple, nonblanching, macular lesions that are 1 to 3 mm in diameter purple macular lesions larger than 1 cm in diameter

pinpoint, pink to purple, nonblanching, macular lesions that are 1 to 3 mm in diameter Petechiae are small pinpoint, pink to purple, macular lesions 1 to 3 mm in diameter. Purple, macular lesions greater than 1 cm in diameter are defined as purpura. A bruise is defined as ecchymosis. A hematoma is a collection of blood.

When collecting data on a neonate for signs of diabetes insipidus, a nurse should recognize which symptom as a sign of this disorder? polyuria and polydipsia hyponatremia jaundice hypochloremia

polyuria and polydipsia The cardinal signs of diabetes insipidus are polyuria and polydipsia. Hypernatremia, not hyponatremia, occurs with diabetes insipidus. Jaundice occurs because of abnormal bilirubin metabolism, not diabetes insipidus. Hyperchloremia, not hypochloremia, occurs with diabetes insipidus.

The parent of a neonate born with a cleft lip and palate prepares to feed the child for the first time. Which parent education should the nurse reinforce as a priority of care before the parent attempts the first feeding? proper positioning of the neonate how to lay the neonate down methods of burping the neonate how to clean the neonate's mouth

proper positioning of the neonate When neonates are held in the upright position, the formula is less likely to leak out the nose or mouth. Neonates need to be burped frequently after feeding. There is no need to clean the mouth before eating and the infant should be positioned after feeding to prevent aspiration. After surgical repair, the mouth is cleaned at the suture site to prevent infection. The bottle should be prepared using a special nipple or feeding device.

An infant with myelomeningocele has a Chiari II malformation. Which finding would indicate this manifestation? back pain below the site of the sac closure changes in urologic functioning rapidly progressing scoliosis respiratory stridor, apneic periods, and difficulty swallowing

respiratory stridor, apneic periods, and difficulty swallowing Children with a myelomeningocele have a 90% chance of having a Chiari II malformation. This may lead to respiratory function problems, such as respiratory stridor associated with paralysis of the vocal cords, apneic episodes of unknown cause, difficulty swallowing, and an abnormal gag reflexes. Scoliosis and urologic function changes occur with myelomeningocele, but these complications aren't specifically related to Chiari II malformation. Lower back pain does not occur because the infant has a loss of sensory function below the level of the cord defect.

An infant with hypothyroidism is receiving oral thyroid hormone. Which finding should alert a nurse to a potential overdose? bradycardia, irritability, and cool extremities bradycardia, excessive sleepiness, and dry, scaly skin tachycardia, irritability, and diaphoresis tachycardia, cool extremities, and irritability

tachycardia, irritability, and diaphoresis Clinical manifestations of thyroid hormone overdose in an infant include tachycardia, irritability, and diaphoresis. Bradycardia; excessive sleepiness; dry, scaly skin; and cool extremities are manifestations of hypothyroidism or inadequate hormone replacement (underdosage).