peds infant - evolve
An infant is admitted to the neonatal intensive care unit with exstrophy of the bladder. What covering should the nurse use to protect the exposed area? 1 Loose diaper 2 Dry gauze dressing 3 Moist sterile dressing 4 Petroleum jelly gauze pad
3 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.
A nurse is caring for an infant with hypertrophic pyloric stenosis. A pyloromyotomy is scheduled. Which pathophysiologic modification must be addressed before this surgery can be performed safely? 1 Hydration must be restored. 2 The serum chloride level must be restored. 3 Fluid and electrolyte imbalances must be corrected. 4 Malnutrition and respiratory problems must be corrected.
3 The risks of surgery are greatly increased unless dehydration and metabolic alkalosis from prolonged vomiting are corrected. Although adequate hydration must be achieved, electrolyte balance must be restored as well. Although the chloride level is low, the fluid imbalance must be corrected as well. Malnutrition will be corrected after surgery when the infant retains feedings. Respiratory problems are not associated with pyloric stenosis.
The nurse prepares to discharge a newborn from the hospital. Which placement of the infant by the father indicates an understanding of the nurse's education regarding car seat safety? 1 Back seat, facing forward 2 Front seat, facing forward 3 Front seat, facing backward 4 Back seat, facing backward
4 Children younger than 2 years should be placed in a rear-facing car seat secured in the back seat. Placing young children in the front seat is dangerous and could even be fatal if the air bag deploys. Once the child weighs 35 to 40 lb (15.9 to 18.1 kg), a front-facing car seat may be used. Children should sit in the back seat until they are 13 years old.
To prevent skin breakdown on the scalp of an infant with hydrocephalus, how should the nurse position the infant? 1 On either side and flat 2 Supine and Trendelenburg 3 Prone, with the legs elevated about 30 degrees 4 Supine, with the head elevated about 45 degrees
4 The head should be elevated, allowing gravity to minimize intracranial pressure. The Trendelenburg position is contraindicated because it can increase intracranial pressure. The infant may be positioned on the back or side to allow routine changes in head position.
A nurse is teaching a group of parents why it is so important to prevent lead poisoning. The nurse notes that which problem is most associated with infants who are exposed to lead in the environment? 1 Chronic pain 2 Dental caries 3 Cognitive impairment 4 Compromised nutrition
3 Children who are exposed to lead are at risk for lead poisoning, which causes multisystem damage with the worst effects in the central nervous system. Lead poisoning can result in seizures, cognitive impairment, and death. Although abdominal cramps and headache may be symptoms of chronic lead poisoning, they are not the primary problems as lead poisoning progresses and central nervous system symptoms appear. The development of dental caries is not related to lead exposure and poisoning. The child may not be malnourished; plumbism can occur if the child eats paint or plaster chips (pica) containing lead in addition to the diet or if there are lead particles in the atmosphere that the child inhales.
An infant is born with a cleft lip. What nursing intervention is unique to infants with cleft lip? 1 Changing the infant's position often 2 Using modified techniques for feeding 3 Monitoring the infant's daily intake and output 4 Keeping the infant's head elevated during feedings
2 Infants with a cleft in the lip are unable to suck like other newborns because they cannot form a vacuum to draw milk from the nipple. Frequent position changes are common for all infants, not just ones with cleft lip. Monitoring of intake and output is not necessary because hydration is maintained once a feeding method has been established. All infants should be fed with the head elevated to avoid pooling of milk in the mouth, which could result in aspiration.
During discharge planning the parents of an infant with spina bifida express concern about skin care and ask the nurse what can be done to avoid problems. What is the best response by the nurse? 1 Diapers should be changed at least every 4 hours. 2 Frequent diaper changes with cleansing are needed. 3 Medicated ointment should be applied six times a day. 4 Powder may be used in the perineal area when it becomes wet.
2 Infants with spina bifida often exhibit dribbling of urine; they need meticulous skin care and frequent diaper changes to prevent skin breakdown. Changing diapers every 4 hours is insufficient and may result in skin breakdown. Medicated ointments are unnecessary; if a skin irritation develops and an ointment becomes necessary, it should be prescribed by the healthcare provider. Powder will not keep the skin dry; when powder mixes with urine, it forms a pastelike substance that promotes skin breakdown. Also, powder is toxic if inhaled and should be avoided.
A nurse is teaching parents about treating their infant's recurrent attacks of spasmodic croup at home. What is the desired effect of the actions that the nurse teaches the parents? 1 Dilation of the bronchi 2 Reduction of the fever 3 Depression of the cough 4 Interruption of the spasm
4 Spasms must be interrupted, or hypoxia will occur. Fever and cough are not life threatening and are not the priority. Dilation of the bronchi is not the goal.
A nurse is counseling the family of an infant who is HIV positive. Where is the best place for this infant to receive long-term care? 1 Pediatric unit 2 Critical care unit 3 Home environment 4 Extended-care facility
3 Unless there is an episode of acute illness, home is the best place for the infant; this prevents hospital-acquired infection and promotes family interaction. A pediatric unit is required for episodes of acute illness that cannot be handled at home. Critical care is not required unless the illness is exacerbated. An extended-care facility may be needed only if the home environment cannot meet the infant's physical and emotional needs.
A 4-month-old infant is admitted to the pediatric unit with severe tachypnea, flaring of the nares, wheezing, and irritability. The parents are told that the child has bronchiolitis and needs to be hospitalized for observation and treatment. While assessing the infant, the nurse determines that the infant is in respiratory failure. What clinical finding supports the nurse's conclusion? 1 Wheezing cough 2 Intercostal retractions 3 Fine crackles on deep inspiration 4 Sudden absence of breath sounds
4 A sudden absence of breath sounds occurs when bronchioles become obstructed and respiratory failure is imminent. A wheezing cough is a common manifestation of bronchiolitis and is caused by the passage of air through the narrowed airways; it does not herald respiratory failure. Intercostal retractions occur with mild and moderate respiratory distress in infants. Fine crackles are a routine occurrence with bronchiolitis, not a sign of respiratory failure.
A 1-month-old infant is being treated with sequential casts for bilateral clubfoot (talipes equinovarus); new casts have just been applied. The goal at this time is ensuring that circulation to the feet remains sufficient. How will the nurse determine that the goal is being met? 1 The cast is intact and there is no drainage. 2 There are no signs of pain in the extremities. 3 There is range of motion in the hips and knees. 4 The toes, when compressed, exhibit a quick return of circulation.
4 Circulation to the feet can best be measured by applying pressure to the toes; a rapid return of color indicates adequate circulation. Both feet should be assessed and the responses compared for adequacy of circulation and symmetry. Drainage or no drainage on the cast is not an indicator of adequate circulation. An infant cannot express pain in a specific area; if the infant is uncomfortable, the infant will probably cry and be irritable. Flexion of the hips and knees does not indicate blood flow to the feet.
A 7-month-old girl is to be catheterized so a sterile urine specimen may be obtained. One of the infant's parents expresses fear that this procedure may traumatize the baby psychologically. How should the nurse provide reassurance? 1 The fear is justified, and the nurse should obtain a "clean catch" specimen. 2 Parents have a right to refuse the catheterization, and the concerns are realistic. 3 Although the concern is appropriate, the need for a sterile specimen is the priority. 4 The procedure is uncomfortable, but there should not be a damaging long-term effect.
4 The 7-month-old infant is accustomed to having the perineal area exposed and cared for and is not in a developmental stage in which fears related to sexuality are present. A "clean catch" at this age is often contaminated; therefore catheterization has been prescribed. The parents do have the right to refuse, but this concern is not realistic an infant of this age. The parent's concern is not appropriate for the developmental age of the infant.
A mother brings her 9-month-old infant to the clinic. The nurse is familiar with the mother's culture and knows that belly binding to prevent extrusion of the umbilicus is a common practice. The nurse accepts the mother's cultural beliefs but is concerned for the infant's safety. What variation of belly binding does the nurse discourage? 1 Coin in the umbilicus 2 Tight diaper over the umbilicus 3 Binder that encircles the umbilicus 4 Adhesive tape across the umbilicus
1 A coin may be dislodged, allowing the infant to put it in his or her the mouth, resulting in a safety issue. A diaper fastened tightly around the waist, a binder, or adhesive tape over the umbilicus will not endanger the infant. Cultural beliefs that do not place the infant at risk should not be discouraged.
On a routine visit to the pediatric clinic, the mother of a 6-week-old infant tells the nurse that her baby has the "cutest little folds on her legs, two on one side, and three on the other." What might this sign indicate? 1 Hip dysplasia 2 Neonatal obesity 3 Slipped epiphysis 4 Talipes equinovarus
1 Asymmetrical hip and thigh folds are indicative of developmental dysplasia of the hip; they are caused by upward and outward displacement of the femoral head on the affected side. Extra folds are bilateral if the infant is obese. A slipped epiphysis is found in the school-age child; it is characterized by a limp and pain in the leg. Clubfoot is a deformity of the foot, not the hip.
A nurse is teaching parenting skills to a group of teenage mothers. After a discussion of child safety, the young mothers provide feedback. Which comment indicates the need for additional information? 1 "My baby could drown if I leave her alone in water higher than her waist." 2 "My baby could swallow any item small enough for him to put in his mouth." 3 "My baby will be safest in the car if I put the car seat in the middle of the back seat." 4 "My baby will touch everything when she starts to crawl, so I'll cover all of the electrical outlets."
1 Drowning can occur in even a minimal amount of water, because the infant does not have the body control to move out of the water. Babies can swallow any small item left in their reach. The middle of the back seat is the best location for the car seat. Before the infant becomes mobile, the mother will need to take precautions to prevent electrical injury.
Electrocardiography (ECG) is scheduled for an infant who has tetralogy of Fallot. The mother asks the nurse what type of test this is and why it is done. What is the best response by the nurse? 1 "It's a type of x-ray that shows us the size of the baby's heart." 2 "Electrical activity in the baby's heart is recorded, then printed on graph paper." 3 "It's an ultrasound procedure that produces images of the structures in the baby's heart." 4 "Contrast material is injected into the baby's vein to visualize the flow of blood through the heart."
2 An ECG not only records electrical impulses in the heart but can also reveal atrial and ventricular hypertrophy. The x-ray procedure that shows the size of a baby's heart is a chest x-ray. The ultrasound procedure that would be used to produce images of the structures in a baby's heart is the echocardiogram. The intravenous injection of contrast material to visualize the flow of blood through the heart is an angiogram.
A nurse provides clapping, percussion, and postural drainage every 4 hours for a 3-month-old infant with cystic fibrosis. When is the best time for the nurse to schedule chest physiotherapy? 1 During every feeding 2 Two hours after feedings 3 Right after every feeding 4 Right before every feeding
2 Chest physiotherapy is done midway between feedings (about 2 hours before or after a feeding). This will decrease the likelihood of vomiting and increase drainage of respiratory secretions. Performing chest physiotherapy right after a feeding may cause the infant to vomit the feeding. Performing chest physiotherapy right before a feeding will tire the infant and possibly lead to impaired nutritional intake. Performing chest physiotherapy during a feeding is contraindicated; the infant may vomit, and nutritional intake will be impaired.
On a visit to the well-baby clinic the parents are upset because their 9-month-old infant has severe diaper rash; one parent wants to know how to treat it and prevent it from recurring. What cause of diaper dermatitis should the nurse include when answering the parent's question? 1 Use of disposable diapers 2 Prolonged contact with an irritant 3 Decreased pH of the infant's urine 4 Too-early introduction of solid foods
2 Diaper dermatitis is caused by prolonged repetitive contact with an irritant (e.g., urine, feces, soaps, detergents, ointments, friction). Both cloth and disposable diapers can cause diaper dermatitis if they are not changed frequently. An increased pH (i.e., alkaline) of the urine can contribute to diaper dermatitis. A change in diet may contribute, but there is no evidence that this is directly related.
What is the priority nursing action in the care of a young child with severe diarrhea? 1 Measuring daily urine output 2 Maintaining fluid and electrolyte balance 3 Replacing the lost calories with high-fiber foods 4 Promoting perianal skin integrity by bathing often
2 Maintaining fluid and electrolyte balance is the priority intervention to reduce risk of harm to the patient. Measuring daily urine output is important as a means of checking kidney function, but maintaining overall fluid and electrolyte balance is the priority. If a child is severely dehydrated, urine output needs to be checked more often than daily. Nutrition is not a priority above fluid and electrolyte balance at this time. Although important, skin integrity is not the priority.
The parents of an infant ask a nurse why their baby is not receiving the measles, mumps, and rubella (MMR) vaccine at the same time that other immunizations are being given. What explanation should 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. 2 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.
2 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.
A nurse is teaching a parent how to prevent accidents while caring for a 6-month-old infant. What ability should be emphasized with regard to the infant's motor development? 1 Sits up 2 Rolls over 3 Crawls short distances 4 Stands while holding on to furniture
2 Muscle coordination and perception are developed enough at 6 months for the infant to roll over. If unaware of this ability, the parent may leave the infant unattended for a moment to reach for something, making it possible for the infant to roll off an elevated surface. Sitting up unsupported is accomplished by most infants at 7 to 8 months. Crawling takes place around 9 months of age. Standing by holding on to furniture is accomplished by most infants between 8 and 10 months of age.
The parents of a child who is scheduled for open-heart surgery ask why their child must be subjected to chest tubes after surgery. What should the nurse consider before responding in language that the parents will understand? 1 Chest tubes increase tidal volume. 2 Chest tubes facilitate drainage of air and fluid. 3 Chest tubes maintain positive intrapleural pressure. 4 Chest tubes regulate pressure on the pericardium and chest wall.
2 The intrapleural space must be drained of fluid and air to facilitate the reestablishment of negative pressure in the intrapleural space. The tidal volume increases as the lung reexpands, but it is not the reason for the insertion of chest tubes. Intrapleural pressure should be negative, not positive; positive intrapleural pressure causes collapse of the lung. Closed chest drainage is related to intrapleural pressure, not pericardial and chest wall pressure.
A nurse is caring for an infant with tetralogy of Fallot. What clinical finding should the nurse expect when assessing this child? 1 Slow respirations 2 Clubbing of the fingers 3 Subcutaneous hemorrhages 4 Decreased red blood cell count
2 The mixing of oxygenated and deoxygenated blood results in tissue hypoxia; clubbing occurs as a result of additional capillary development and tissue hypertrophy of the fingertips. The respirations are rapid, not slow. The child's problems are related to decreased oxygenation, not to a clotting defect. The body attempts to compensate for the hypoxemia associated with tetralogy of Fallot by increased erythropoiesis.
A postpartum nurse is reviewing principles related to automobile infant restraint systems with the parents of a newborn who is to be discharged in the morning. What information should be included in the teaching session? Select all that apply. 1 Use a forward-facing infant car seat. 2 Secure the infant seat so that it faces the rear. 3 Position the seat between the driver's and passenger's seats in the front seat. 4 Follow the manufacturer's directions to secure the infant seat in the back seat. 5 Be sure to follow weight guidelines set forth in the manufacturer's instructions.
245 An infant seat should face the rear, not the front, of the automobile, because the head and neck are better protected from a whiplash injury in the event of an accident. Research demonstrates that passengers in the front seat sustain more serious injuries than do individuals in the rear seat in most accidents. Using a forward-facing infant car seat and positioning the seat between the driver's and passenger's seats in the front seat is dangerous for the infant and not recommended by the infant car seat safety information guidelines.
What is the nurse's priority concern when caring for an infant born with exstrophy of the bladder? 1 Urine retention 2 Excoriation of the skin 3 Impending dehydration 4 Development of an infection
4 The constant seepage of urine from the exposed ureteral orifices makes the area susceptible to infection; infection must be prevented or controlled because it may ultimately lead to renal failure. Urine retention will not occur because of the constant seepage of urine. Although skin excoriation is a major concern, it is secondary to the development of a life-threatening infection. Although dehydration is a major concern, risk for infection is the priority for the infant at this time.
A 1-week-old infant has been in the pediatric unit for 18 hours after placement of a spica cast. The nurse obtains a respiratory rate slower than 24 breaths/min; no other changes are noted. Because the infant is apparently well, the nurse does not report or document the slow respiratory rate. Several hours later the infant experiences severe respiratory distress, and emergency care is necessary. What should be considered if legal action is taken? 1 Most infants' respirations are slow when they are uncomfortable. 2 The respirations of young infants are irregular, so a drop in rate is unimportant. 3 Vital signs that are outside the expected parameters are significant and should be documented. 4 The respiratory tracts of young infants are underdeveloped, and the respiratory rate is not significant.
3 A respiratory rate of less than 30 breaths/min in a young infant is not within the expected range of 30 to 60 breaths/min; a drop to less than 30 breaths/min is a significant change and should be documented. Respirations will accelerate when there is discomfort. Any significant change should be reported immediately. The respiratory tract is fully developed at birth, and the respiratory rate is a cardinal sign of the infant's well-being.
What is the nurse's priority intervention when preparing for admission of a child with acute laryngotracheobronchitis? 1 Padding the side rails of the crib 2 Arranging for a quiet, cool room 3 Placing a tracheostomy unit by the bedside 4 Obtaining a recliner so a parent can stay
3 The priority is a patent airway; the equipment needed to ensure a patent airway must be immediately available. Although padding the rails of the crib is helpful, it is not the priority. Arranging for a quiet, cool room is unnecessary; it may be done if the child has a high fever or a history of febrile seizures. Although it is appropriate to obtain a recliner so a parent may stay, this is not the priority.
What should the nursing care of an 8-month-old infant with tetralogy of Fallot include? 1 Restriction of fluid intake to conserve energy 2 Provision of iron-fortified formula to prevent anemia 3 Administration of coagulants to control bleeding tendencies 4 Prevention of increased respiratory effort to promote oxygenation
4 Preventing respiratory distress minimizes the workload of the heart; this is accomplished with such interventions as positioning, maintaining diet restrictions, administering medications, and promoting conservation of energy. Restriction of fluid intake will promote hemoconcentration; if oral fluids are limited to conserve energy, intravenous fluids may be indicated. Additional iron intake will aggravate the polycythemia that results from hypoxia caused by reduced pulmonary blood flow. Administration of coagulants along with hemoconcentration is conducive to thrombus formation.
A parent tells the nurse, "My 9-month-old doesn't have the same strong grasp that she had when she was born, and she's not startled by loud noises anymore." How should the nurse explain these changes in behavior? 1 "Let me check these responses before deciding how to proceed." 2 "When these responses fail, it may indicate a developmental delay." 3 "The baby needs more sensory stimulation to get these responses back." 4 "Those responses are replaced by voluntary activity around 5 months of age."
4 Touching the palm of a newborn causes flexion of the fingers (grasp reflex ); this response usually diminishes after 3 months of age. An unexpected loud noise causes the newborn to abduct the extremities and then flex the elbows (startle reflex); this response usually disappears by 4 months of age. Persistence of primitive reflexes is usually indicative of a developmental delay. It is not necessary to gather more data, because these changes are consistent with expected growth and development. The data do not support the conclusion that the child is developmentally delayed, and saying so may cause needless concern. Sensory stimulation at this age is directed toward experiences to add new motor, language, and social skills.
A 10-month-old infant is in a restaurant with parents and grandparents. The grandfather places several pieces of bread on the high chair tray for the infant. A nurse sitting nearby sees the infant gag and become red-faced, then turn cyanotic. With permission from the family, the nurse holds the child with the head downward and does what? 1 Gives the infant five back blows 2 Sweeps the infant's mouth with a finger 3 Performs five abdominal thrusts on the infant 4 Initiates the head tilt-chin lift maneuver on the infant
1 Infants younger than 1 year of age who experience an airway obstruction should be held with the head down and given five back blows. If the obstruction is not removed, the infant is turned and given five chest thrusts. The two actions are alternated until the obstruction is dislodged or the infant loses consciousness. Infants and children should not be subjected to blind finger sweeps, because the finger could push the obstruction farther down the pharynx or trachea. The abdominal thrust (Heimlich maneuver) is the first action for children older than 1 year and adults. If the infant becomes unconscious, a modified head tilt-chin lift is performed before the initiation of resuscitation.
What is the best way for the nurse to promote the social development of a 9-month-old infant? 1 Engaging in peek-a-boo 2 Offering soft clay to manipulate 3 Providing a pegboard for pounding 4 Demonstrating how to speak words
1 Playing peek-a-boo is age appropriate because it aids the infant's social development by fostering a sense of object constancy and object permanence. Playing with soft clay is age appropriate for the toddler; it promotes gross and fine motor development. Pounding on a pegboard is age appropriate play for toddlers and preschoolers; it helps release tension and develops motor skills. Repeating words is age appropriate for the 1-year-old child.
The nurse is teaching the parents of an infant who will have frequent cast changes about cast care. What suggestion should be included in the teaching? 1 Assess the skin at the edges of the cast. 2 Apply lotion to the skin at the cast's edges. 3 Immerse the cast briefly during the tub bath. 4 Cover the damp cast edges with adhesive petals.
1 Rough cast edges can cause skin irritation and breakdown. Lotions applied to the skin at the edges of a cast can also promote skin breakdown. The skin under the cast may become macerated as a result of inadequate drying after water immersion. Adhesive petals will not adhere to a damp cast even if the cast is composed of fiberglass; it takes about a half-hour for it to dry.
A 2-month-old infant is to have a nasogastric tube inserted. What does the nurse expect to happen? 1 A pacifier will be offered to decrease gagging and allow easier insertion of the tube. 2 Gastric contents will not appear in the tube if the infant is receiving nothing by mouth. 3 Coughing, irregular breathing, and slight cyanosis will occur during introduction of the tube. 4 The tube will be passed a distance equal to the length from the chin to the tip of the sternum.
1 Sucking and swallowing (the infant's response to a pacifier) reduce gagging and facilitate the insertion of the nasogastric tube. A small amount of gastric fluid is always present and will appear in the tube. The tube is passed the distance from the ear to the tip of the nose to the distal end of the sternum. Coughing, gagging, and cyanosis are indications that the tube has passed into the larynx, not the stomach.
An infant with tetralogy of Fallot begins to cry frantically and exhibits worsening cyanosis and dyspnea. In which position should the nurse place the child? 1 Knee-chest 2 Orthopneic 3 Lateral Sims 4 Semi-Fowler
1 The knee-chest position decreases circulation to and from the extremities, thereby improving circulation to the heart and lungs and increasing oxygenation. The knee-chest position has the same effect as the squatting that is seen in the older child with tetralogy of Fallot. Blood circulating in the heart and lungs has a lower oxygen content when the child is in the orthopneic position than it does with the child in the knee-chest position. Blood circulating in the heart and lungs has a lower oxygen content when a person is in the semi-Fowler position or lateral Sims position.
The mother of an infant who just underwent cleft lip repair tells the nurse, "He seems restless. May I hold him?" What information influences the nurse's response? 1 Holding may meet needs and reduce tension on the suture line. 2 Sedation limits activity and decreases tension on the suture line. 3 Handling may increase irritability, causing tension on the suture line. 4 Arm movements cannot be controlled, placing tension on the suture line.
1 Touching and cuddling provide a sense of well-being and relieve strain on the suture line that results from restlessness and crying. It is inappropriate to sedate an infant for its calming effect or to decrease activity. Careful handling will not damage the suture line. Arm movement can be controlled by applying elbow restraints to prevent the infant's hands from touching the suture line.
On the day after surgery for insertion of a ventriculoperitoneal shunt to treat hydrocephalus, an infant's temperature increases to 103.0° F (39.4° C). The nurse immediately notifies the practitioner. What is the next nursing action? 1 Covering the infant with a bath blanket 2 Sponging the infant with tepid alcohol 3 Removing excess clothing from the infant 4 Reassessing the infant's temperature in several hours
3 After the initial safety measures and notification of the practitioner have been addressed, excess clothing, which prevents heat loss, should be removed. Covering the infant will increase the temperature because heat loss will be reduced. Alcohol should never be used for infants or children; it causes severe chilling, which can lead to increased metabolic activity and a higher temperature. This high fever requires more frequent readings, usually at least every hour.
