Pediatric Nursing-Infants
Which assessment finding would the nurse recognize as common in infants with Down syndrome? 1 Bulging fontanels 2 Stiff lower extremities Correct3 :Abnormal heart sounds 4 Unusual pupillary reactions
Cardiac anomalies (that produce abnormal heart sounds) often accompany genetic problems such as Down syndrome; 30% to 40% of affected infants also have congenital heart defects.
Which rationale would the nurse expect for a mother being reluctant to feed her 6-week-old infant who recently had surgery for hypertrophic pyloric stenosis (HPS)? Correct1 Afraid that her baby's vomiting will resume 2 Unaware that she is allowed to feed her baby 3 Not sure how to feed her baby with a special nipple 4 Uncertain whether her baby will tolerate the thickened formula
Previous experiences with projectile vomiting are frightening; the nurse should explain that this should not recur and encourage the mother to resume feeding her baby. The data indicate that the mother knows she is allowed to feed her baby but is reluctant to do so. A special nipple is not required. Thickened formula is not necessary after surgery.
At which age will an infant's anterior fontanel close? 1 6 to 8 months of age 2 9 to 12 months of age Correct3 12 to 18 months of age 4 19 to 36 months of age
According to the standards of growth and development, the anterior fontanel closes between 12 and 18 months of age. Six to 8 months and 9 to 12 months are both too early; early closure may impede the growth of the infant's brain, impairing mental development. The closure should occur by 18 months; delayed closure may indicate neurological problems.
The nurse is reviewing the laboratory report of an infant with tetralogy of Fallot that shows an increased red blood cell (RBC) count. Which would the nurse identify as the cause of the polycythemia? 1 Low blood pressure 2 Diminished iron level Correct3 Tissue oxygen needs 4 Hypertrophic cardiac muscle
Decreased tissue oxygenation stimulates erythropoiesis, resulting in excessive production of RBCs. Low blood pressure and hypertrophic cardiac muscle are not direct causes of polycythemia. Diminished iron level may or may not affect the production of RBCs.
Which parent teaching would the nurse provide to prevent vomiting in an infant who had corrective surgery for hypertrophic pyloric stenosis? 1 Rock the infant. Correct2 Keep the infant's head elevated. 3 Place the infant flat on the right side. 4 Keep the infant awake with sensory stimulation.
Elevating the infant's head helps prevent vomiting through the use of gravity. Movement increases the chance of vomiting. Placing the infant flat on the right side will not prevent vomiting and may result in aspiration. Activity increases the chance of vomiting.
Which age would a child be able to drink from a cup? 1 5 months 2 7 months 3 12 months 4 18 months
3 12 months By 12 months of age, a child can usually drink from a cup, although fluid may spill and a bottle may be preferred at times. The child is just beginning to exert lip control at 5 months and cannot handle a cup. At 7 months, a child can handle a bottle but not a cup. This skill is present at 12 months, and by 18 months most children are quite proficient.
Which explanation would the nurse provide the mother of an infant who vomits the first feeding after corrective surgery for hypertrophic pyloric stenosis? 1 "This often occurs after the first feeding." 2 "The baby is ridding postoperative mucus." 3 "Your feeding technique may need to be changed." 4 "Feedings will have to be stopped until peristalsis improves."
Correct 1: "This often occurs after the first feeding." Explaining that the first postoperative feeding usually induces vomiting provides correct information while supporting the anxious parent. Vomiting is not caused by mucus accumulation. Questioning the mother's feeding technique may cause guilt; although the feeding technique may need to be changed, discussing it at this time is inappropriate. When the vomiting subsides, the feeding is continued.
During the respiratory assessment of an 8-month-old infant, the nurse notes bronchial breath sounds over areas of consolidation, mild substernal retractions, profuse nasal mucus production, pallor, and a temperature of 102°F (38.9°C). Which action would the nurse take? Correct1 Suction the nasopharynx so a patent airway can be maintained. 2 Start an intravenous infusion to provide necessary fluids and electrolytes. 3 Call the respiratory therapist to start preparations for oxygen administration. 4 Administer an antipyretic for the fever
Establishment and maintenance of a patent airway is always the priority. This intervention follows the ABCs (airway-breathing-circulation) of emergency care. An intravenous infusion may be needed, but would require a practitioner prescription. The practitioner, not the respiratory therapist, would be consulted about oxygen administration. Antipyretics must be prescribed by a practitioner before administration.
Which assessment would the nurse perform to monitor for a major complication in an infant after surgery to correct a myelomeningocele? 1 Daily weights 2 Fluid output every 8 hours 3 Blood pressure every 12 hours Correct4 Daily head circumference measurements
Hydrocephalus, which may occur after surgical correction, is a major complication of myelomeningocele. Measuring the daily head circumference provides an accurate basis for day-to-day comparisons. Although important, daily weights are not specific to monitoring for a developing hydrocephalus. An infant's output is unrelated to hydrocephalus. Vital signs should be taken every 2 to 4 hours after surgery.
Which behavior would the nurse determine is developmentally appropriate in a healthy 5-month-old infant? 1 Using the pincer grasp 2 Sitting without support 3 Crawling across the floor Correct4 Grasping objects voluntarily
The 5-month-old infant's neurological development has reached the stage at which objects can be grasped voluntarily; this is considered a developmental milestone. The pincer grasp appears between 9 and 12 months of age. Sitting alone without support is usually accomplished at 6 to 8 months of age. The infant begins to crawl at 8 to 10 months of age.
Which covering would the nurse use over the exposed area of an infant admitted with exstrophy of the bladder? 1 Loose diaper 2 Dry gauze dressing Correct3 Moist sterile dressing 4 Petroleum jelly gauze pad
The bladder membrane is exposed; it must remain moist and, as much as possible, sterile. A loose diaper and a dry gauze dressing will each allow the exposed membrane to dry out, increasing the risk for infection. Petroleum jelly will adhere to the membrane, resulting in trauma
Which parent education would the nurse give about why the MMR vaccine is administered at 12 to 15 months of age? 1 There is an increased risk of side effects in infants. Correct2 Maternal antibodies provide immunity for about 1 year. 3 It interferes with the effectiveness of vaccines given during infancy. 4 There are rare instances of these infections occurring during the first year of life.
Maternal antibodies to measles, mumps, and rubella infection persist in the infant until approximately 15 months of age. Side effects are no more common among infants than in toddlers. The measles vaccination does not interfere with the effectiveness of other vaccines. Although the measles, mumps, and rubella do occasionally occur after the administration of the MMR vaccine during the first year of life, the vaccine is not given during this time because of the presence of maternal antibodies.
An infant being treated for talipes equinovarus (clubfoot) has a cast change every 2 to 3 weeks. Which assessments would the nurse include at routine visits? Select all that apply. One, some, or all responses may be correct. 1 Pedal pulses of both feet 2 Range of motion of the foot in the cast Correct3 Color of the toes of the foot in the cast Correct4 Movement of the toes of the foot in the cast 5 Knee flexion and extension of the affected leg
Skin color will indicate adequate (e.g., same color as the rest of the body's skin) or impaired (e.g., dusky, cyanotic) circulation in the foot in a cast. Movement will indicate unimpaired neural transmission in the foot. Pedal pulses will not be accessible on the foot in a cast. A foot cannot be put through its full range of motion with a cast in place. Knee flexion and extension are irrelevant; the knee is not involved with a foot in a cast.
The nurse anticipates that a child born with a missing chromosome is most likely to have which condition? 1 Cretinism 2 Phenylketonuria 3 Down syndrome
Turner syndrome results from a missing X chromosome; these females have an XO configuration rather than XX. Cretinism occurs in the presence of thyroid hormone deficiency. Phenylketonuria is an autosomal recessive single-gene disorder. Down syndrome results from extra genetic material on chromosome 21.
Which developmental milestones would the nurse expect a 6-month-old infant to demonstrate? 1 Sitting alone, displaying pincer grasp, and waving bye-bye 2 Pulling up to a standing position, releasing a toy by choice, and playing peek-a-boo 3 Crawling, transferring a toy from one hand to the other, and displaying fear of strangers Correct4 Turning over completely, sitting momentarily without support, and reaching to be picked up
Turning over completely, sitting momentarily without support, and reaching to be picked up are age-appropriate actions in 6-month-old infants. The ability to sit alone, display a pincer grasp, and wave bye-bye; pull up to a standing position, release a toy by choice, and play peek-a-boo; and crawl, transfer a toy from hand to hand, and display fear of strangers should have developed by 10 months of age.
An infant with severe developmental dysplasia of the hip has a hip spica cast applied. Which instruction would the nurse give the parents to help prevent a serious complication? 1 Change diapers frequently. 2 Decrease the number of feedings per day. 3 Call the primary health care provider if a foul smell is detected. 4 Avoid turning the child from the prone to the supine position.
Correct 3: Call the primary health care provider if a foul smell is detected. A foul smell emanating from the cast may indicate the development of an infection and necessitates immediate intervention to prevent sepsis, which is a serious complication involving tissue infection that has worsened to become a bloodstream infection. Soiling of the cast with excreta, although problematic, is not a serious complication.
The nurse provides nutritional counseling to the parents of a 6-month-old formula-fed infant who will begin eating solid foods. Which statement by a parent indicates understanding of the nurse's advice? CORRECT 1: "I'll keep giving my baby formula instead of regular cow's milk." 2: "I'll buy plenty of pureed spinach so my baby gets enough iron." 3:"Using a natural sweetener like honey is better than using table sugar." 4:"I'll feed my baby a few bites from the jar, then save the rest for later."
Infants should receive formula or breast milk for a full year; cow's milk should not be introduced until 1 year of age. Commercially prepared spinach, collard greens, and certain other foods contain nitrates and so should be used very sparingly; if the infant is iron deficient, other sources should be used. Honey should not be given to infants under 1 year of age because there is risk of botulism poisoning. If feeding an infant food from the jar, the jar should be discarded after one serving. Reusing the jar of food risks contamination. Alternatively, put a small serving of food on a clean dish and refrigerate the remaining food in the jar.
Which behavior would the nurse expect when approaching a 4-month-old infant who was admitted to the pediatric unit? 1 Smile socially in recognition of the nurse 2 Cry when the nurse approaches for the first time Correct3 Reach out to the nurse for the attention that is being offered 4 Cling to the mother when the nurse tries to establish contact
The infant has not yet recognized boundaries between self and mother, and is not particular about who meets and resolves needs. The infant is most likely reaching out for attention, and so the nurse can provide that attention. A social smile does not indicate recognition of a specific person, only a human face. The infant does not yet differentiate familiar faces from those of strangers, so the infant would not cry because the nurse approaches. The infant does not understand or fear separation from the mother yet.
Which education would the nurse provide the parents of an infant with cerebral palsy to support setting care goals? 1 Cognitive impairments require special education. 2 Progressive deterioration requires future institutionalization. Correct3 Unknown extent of the disability requires continual adjustments. 4 Diminished immune responses require protection from infection.
The infant is too young for specific long-term plans; care planning should incorporate the plan to continually reevaluate care plans because different needs may manifest as the child grows older.
Which statement would indicate to the nurse that the parents of an infant admitted with gastroenteritis understand contact precautions when they note that after washing their hands they need to do which? 1 Put on a mask when holding the baby. 2 Weigh the diaper each time they change the baby. 3 Keep the door to the baby's room closed most of the time. Correct4 Change their gloves each time they change the baby's diaper.
The organisms causing gastroenteritis are eliminated in the feces. The gloves should be removed and the hands washed after giving direct care. New gloves should be donned if the parents are to remain with the child. A mask is required for airborne precautions. Weighing diapers is not a requirement of contact precautions; this technique may be used to measure intake and output. The door to the baby's room should be closed if airborne precautions are necessary.