Peds Chapter 21

Which data cause the nurse to provide the parents of an infant with education regarding colic? 1) Abdominal pain accompanied by crying 3 days per week 2) No weight gain since the last well-child visit 3) Muscle mass that has decreased 4) Frequent emesis

1 1 Colic manifests with abdominal pain accompanied by 3 hours of crying for at least 3 days per week. 2 Education for failure to thrive (FTT), not colic, is required for an infant who does not gain weight between well-child visits. 3 Education for FTT, not colic, is required for an infant with decreased muscle mass. 4 Education for FTT, not colic, is required for an infant with frequent emesis.

Which data cause the nurse to report to the charge nurse that an infant is experiencing moderate dehydration? 1) A 5% weight loss 2) A 15% weight loss 3) A decrease in urine output 4) A delayed capillary refill time

3 1 A 5% weight loss or less indicates mild dehydration. 2 A 15% weight loss or greater indicates severe dehydration. 3 A decrease in urine output is a clinical manifestation associated with moderate dehydration. 4 A delayed capillary refill time is a clinical manifestation associated with severe dehydration.

Which parental statement regarding the sleep needs of a younger infant is accurate? 1) "My baby requires 22 to 23 hours of sleep each day." 2) "My baby requires a 1- to 2-hour nap in the afternoon." 3) "My baby requires a 1- to 2-hour nap in the morning." 4) "My baby requires 16 hours of sleep each day, including two naps."

1 1 During the first few weeks of life, a younger infant requires 22 to 23 hours of sleep per day. This statement indicates correct understanding. 2 An older, not a younger, infant requires 16 hours of sleep each day and takes a 1- to 2-hour nap in the afternoon. This statement indicates the need for further education. 3 An older, not a younger, infant requires 16 hours of sleep each day and takes a 1- to 2-hour nap in the morning. This statement indicates the need for further education. 4 An older, not a younger, infant requires 16 hours of sleep each day, including two naps. This statement indicates the need for further education.

Which complementary therapy might the nurse encourage for an infant who is experiencing colic? 1) Herbal tea 2) Acupressure 3) Stone therapy 4) Massage therapy

1 1 Some cultural groups have found that herbal tea decreases the irritability and crying associated with colic. 2 There is no evidence to support the use of acupressure in the treatment of infant colic. 3 This is no evidence to support the use of stone therapy in the treatment of infant colic. 4 There is no evidence to support the use of massage therapy in the treatment of infant colic.

Which immunizations should the nurse prepare the parents of an infant for during the 4-month well-child visit? (Select all that apply.) 1) Rotavirus 2) Hepatitis B 3) IPV 4) MMR 5) Diphtheria, tetanus, pertussis (DTP)

1,3,5 1. This is correct. The rotavirus immunization is administered during the 4-month well-child visit. 2. This is incorrect. The hepatitis B immunization is not administered during the 4-month well-child visit. 3. This is correct. The IPV immunization is administered during the 4-month well-child visit. 4. This is incorrect. The MMR immunization is not administered during the 4-month well-child visit. 5. This is correct. The DTP immunization is administered during the 4-month well-child visit.

Which nursing actions are included when collecting anthropometric measurements during the newborn assessment? (Select all that apply.) 1) Measuring head circumference 2) Monitoring blood pressure 3) Determining heart rate 4) Documenting length 5) Assessing weight

1,4,5 1. This is correct. Head circumference is an anthropometric measurement; therefore, this nursing action is appropriate. 2. This is incorrect. Blood pressure is a vital sign and not an anthropometric measurement. 3. This is incorrect. Heart rate is a vital sign and not an anthropometric measurement. 4. This is correct. Length is an anthropometric measurement; therefore, this nursing action is appropriate. 5. This is correct. Weight is an anthropometric measurement; therefore, this nursing action is appropriate.

Which statement regarding plotting anthropometric measurements indicates correct parental understanding? 1) "Body mass index (BMI) is monitored closely during the first year of life." 2) "Height, weight, and BMI are monitored from 3 to 18 years of age." 3) "You will plot my baby's weight, length, and head circumference through 4 years of age." 4) "There are four charts used to monitor physical growth from birth to 18 years of age."

2 1 BMI is monitored at 3 years of age; therefore, this parental statement indicates the need for additional education. 2 Height, weight, and BMI are monitored from 3 to 18 years of age; therefore, this parental statement indicates correct parental understanding. 3 Head circumference is not plotted after the age of 3 years; therefore, this parental statement indicates the need for additional education. 4 There are two, not four, charts used to monitor physical growth from birth to 18 years of age; therefore, this parental statement indicates the need for additional education.

Which nursing action is appropriate when assessing an infant for respiratory distress? 1) Palpating for masses 2) Inspecting for head bobbing 3) Documenting the frequency of stools 4) Monitoring for visible loops of bowel

2 1 Palpating for masses is an appropriate nursing action when assessing for gastrointestinal issues, not respiratory distress. 2 Head bobbing is often an indication of respiratory distress. 3 Documenting the frequency of stools is an appropriate nursing action when monitoring for gastrointestinal issues, not respiratory distress. 4 Monitoring for visible loops of bowel is an appropriate nursing action when monitoring for gastrointestinal issues, not respiratory distress.

Which data obtained during an infant's health history interview cause the nurse to provide specific information about SIDS? 1) Sleeping on the back 2) Smoking in the home 3) Attending day care each day 4) Being behind on current vaccinations

2 1 Prone sleeping indicates the need for education regarding SIDS prevention. 2 Exposure to secondhand smoke increases the risk for SIDS; therefore, this datum indicates the need for education regarding SIDS prevention. 3 Day-care attendance does not indicate the need for education regarding SIDS prevention. 4 Lagging behind with vaccinations does not indicate the need for education regarding SIDS prevention.

At which age should the nurse suggest introducing rice cereal to the infant's diet? 1) 3 months 2) 6 months 3) 9 months 4) 12 months

2 1 Rice cereal is not introduced to the infant's diet at 3 months of age. 2 Rice cereal is introduced to the infant's diet at 6 months of age. 3 Rice cereal is not introduced to the infant's diet at 9 months of age. 4 Rice cereal is not introduced to the infant's diet at 12 months of age.

Which immunization should the nurse plan to give prior to newborn discharge from the hospital? 1) Rotavirus 2) Hepatitis B 3) Inactivated polio virus (IPV) 4) Measles, mumps, rubella (MMR)

2 1 Rotavirus is not an immunization that is administered to the newborn prior to hospital discharge. 2 Hepatitis B is an immunization that is administered to the newborn prior to hospital discharge. 3 IPV is not an immunization that is administered to the newborn prior to hospital discharge. 4 MMR is not an immunization that is administered to the newborn prior to hospital discharge.

Which intervention should be included in the plan of care for an infant who is experiencing diaper rash? 1) Changing the diaper three times per day 2) Keeping the diaper area clean and dry 3) Using scented lotion on the diaper area 4) Applying nystatin cream four times per day

2 1 The diaper should be changed as needed and not just three times per day. 2 The diaper area should be kept clean and dry for all infants, including those experiencing diaper rash. 3 Scented lotions should be avoided, especially in the diaper area. 4 Nystatin cream is appropriate for an infant who is diagnosed with a fungal diaper rash.

Which parental statement about newborn and infant stooling patterns indicates the need for further education? 1) "A formula stool has a soft consistency." 2) "A transitional stool is less thick and sticky." 3) "A breastfed baby will stool only once per day." 4) "A meconium stool is the first stool my baby will have."

3 1 A formula stool should have a soft consistency; therefore, this parental statement indicates correct understanding of the information presented. 2 A transitional stool is less thick and sticky; therefore, this parental statement indicates correct understanding of the information presented. 3 A breastfed baby is expected to stool several times each day; therefore, this parental statement indicates the need for further education. 4 A meconium stool is the first stool a baby passes; therefore, this parental statement indicates correct understanding of the information presented.

Which parental statement indicates understanding of methods to prevent newborn neurological injury? 1) "I should cover my baby's head." 2) "I should place my baby on her back to sleep." 3) "I should never shake my baby, even if she won't stop crying." 4) "I should use the bulb syringe to remove secretions from my baby's nose."

3 1 Although covering the baby's head decreases the risk for cold stress, this statement does not indicate understanding of methods to prevent newborn neurological injury. 2 Although a baby should be placed on her back to sleep to prevent SIDS, this statement does not indicate understanding of methods to prevent newborn neurological injury. 3 A baby should never be shaken, especially when crying. This statement indicates correct understanding of methods to prevent newborn neurological injury. 4 Although using a bulb syringe to remove secretions decreases the risk for aspiration, this statement does not indicate understanding of methods to prevent newborn neurological injury.

Which statement regarding infant physical growth patterns should the nurse share with the parents of an infant? 1) "Your baby will double his birth weight by 3 months of age." 2) "Your baby should double his birth weight by 9 months of age." 3) "Your baby should triple his birth weight by 12 months of age." 4) "Your baby will lose 15% of his body weight by 1 month of age."

3 1 Birth weight is doubled by 6, not 3, months of age. 2 Birth weight is doubled by 6, not 9, months of age. 3 Birth weight should be tripled by 12 months of age. 4 Newborns are expected to lose up to 10% of the birth weight within the first week of life.

Which parental statement indicates the need for further education regarding newborn safety? 1) "I should lay my baby on his back when I put him to sleep." 2) "It is important to support my baby's head when I hold him." 3) "My baby doesn't require a hat unless I am wearing one also." 4) "I shouldn't overextend my baby's shoulders when changing his clothing."

3 1 Newborns should be placed on their backs to sleep to decrease the risk for sudden infant death syndrome (SIDS). 2 Newborns should have their head supported at all times to decrease the risk for injury. 3 Newborns should wear a hat at all times to decrease the risk for cold stress. This statement indicates the need for further education. 4 It is important not to overextend a newborn's joints when changing clothing to prevent injury.

Which assessment data increase the risk for newborn airway compromise? 1) Long torso 2) Long neck 3) Large tongue 4) Large mandible

3 1 The newborn does not have a long torso that leads to airway compromise. 2 The newborn has a short neck, not a long neck that leads to airway compromise. 3 The newborn has a large tongue, which leads to airway compromise. 4 The newborn has a small mandible, not a large mandible that leads to airway compromise.

Which is an example of an anthropometric measurement the nurse documents for the infant in the medical record? 1) Heart rate 2) Pain rating 3) Blood pressure 4) Head circumference

4 1 Heart rate is an example of a vital sign, not an anthropometric measurement. 2 Pain rating is an assessment that is documented with vital signs. It is not an example of an anthropometric measurement. 3 Blood pressure is an example of a vital sign, not an anthropometric measurement. 4 Head circumference is an anthropometric measurement that the nurse documents for the infant in the medical record.

The nurse is calculating the kilocalorie needs for a newborn aged 15 days of life. Which is the maximum number of kilocalories the newborn needs per day if the current weight is 4.5 kg? Record your answer as a whole number. ____________________

495 Feedback: The kilocalorie range for a newborn aged 0 to 30 days of life is 100 to 110 kcal/kg/day. A newborn who weighs 4.5 kg requires a minimum of 450 kcal/day and a maximum of 495 kcal/day.

What is the minimum overall fluid requirement, in milliliters, for a newborn who weighs 5 kg? Record your answer as a whole number. ____________________

625 Feedback: The fluid requirement for newborns and infants up to 6 months of age is 125 to 150 mL/kg/day. A newborn who weighs 5 kg has a minimum fluid requirement of 625 mL/day and a maximum fluid requirement of 750 mL/day.