Infancy - EAQ

Hirschsprung disease

congenital abnormality that results in mechanical obstruction from inadequate motility of part of the intestine

An infant was born 30 minutes ago. The nurse is preparing an injection of vitamin K for the newborn. Which dosage and route will the nurse use? 1.0 to 1.5 mg given intramuscularly 0.5 to 1.0 mg given intramuscularly 1.0 to 1.5 mg given subcutaneously 0.5 to 1.0 mg given subcutaneously

0.5 to 1.0 mg given intramuscularly

The nurse is reviewing the problems that may occur after frequent episodes of otitis media in infants. What complications may be precipitated by this infection?

Mastoiditis Hearing loss Bacterial meningitis

choanal atresia

a lack of an opening between one or both of the nasal passages and the nasopharynx

Meningocele

spina bifida cystica; external saclike protrusion which contains meninges and spinal fluid but NO neural elements

Myelomeningocele

spina bifida cystica; external saclike protrusion which contains meninges, spinal fluid, and nerves; these children usually have lower extremity and bladder dysfunction

Diagnostic test for Cystic Fibrosis

sweat test

While assessing a newborn suspected of having Down syndrome, what does the nurse expect to note as part of the findings? Long, thin fingers Large, protruding ears Hypertonic neck muscles A single line across each palm

A single line across each palm A single line across the palm of each hand, a characteristic finding in newborns with Down syndrome, is known as a simian crease. Stubby fingers and small ears, not long, slim fingers and large, protruding ears, are commonly found in newborns with Down syndrome. Newborns with Down syndrome have hypotonic, not hypertonic, muscles.

A nurse is caring for an infant with hydrocephalus after the insertion of a shunt. How should the nurse evaluate the effectiveness of the shunt? By palpating the anterior fontanel By determining the frequency of voiding By assessing the child for periorbital edema By assessing the symmetry of the Moro reflex

By palpating the anterior fontanel

A nurse is discussing the diet of an 8-month-old infant with the parents. Which foods can an infant of this age on a regular diet safely be fed? Whole milk Pureed pears Pureed carrots Soft-boiled eggs Mashed sweet potatoes

Pureed Pears Pureed Carrotts Mashed Sweet Potatoes Pureed pears, pureed carrots, and mashed sweet potatoes are easily digested foods that are usually introduced by 6 months of age. Breast milk or formula, not whole milk, is recommended for the first year of life. It is preferred that eggs be introduced toward the end of the first year because they may produce an allergic response.

Hirschsprung disease diagnostic test

Rectal biopsy - a specimen is obtained and examined for the absence of ganglion cells. Hirschsprung disease is also known as "congenital aganglionic megacolon"

Tetralogy of Fallot

The four structural defects associated with tetralogy of Fallot are right ventricular hypertrophy, ventricular septal defect, pulmonary stenosis, and overriding of the aorta Clubbing of the fingers can occur because hypoxia leads to poor peripheral oxygenation of tissues, clubbing develops over time as a result of tissue hypertrophy and additional capillary development in the fingers Often patients have polycythemia(high red blood cell count)

Hypertrophic pyloric stenosis

occurs when the circumferential muscle of the pyloric sphincter of the stomach becomes thickened. This thickening may be palpated as an olive-like mass in the upper right quadrant to the right of the umbilicus

Which item should a nurse use to feed an infant born with a unilateral cleft lip and palate? Plastic spoon Cross-cut nipple Parenteral infusion Rubber-tipped syringe

Rubber-tipped syringe Because the infant with a cleft lip and palate is unable to form the vacuum needed for sucking, a rubber-tipped syringe or dropper is used. This allows formula to flow along the sides to the back of the mouth, minimizing the danger of aspiration.

A 2-month-old infant is admitted to the pediatric unit with gastroenteritis and dehydration. Which assessment finding should the nurse anticipate? Bulging fontanels Marked restlessness Resilient tissue turgor Tachycardia

Tachycardia Tachycardia is expected with dehydration because of a decrease in circulating fluid volume. Bulging fontanels are associated with increased intracranial pressure, not dehydration; the fontanels are depressed with dehydration. Because of loss of fluid and electrolytes, the infant is lethargic, not restless. Resilient tissue turgor is associated with an adequate fluid balance.

While changing a newborn girl's diaper a nurse observes a brick-red stain on the diaper. How does the nurse interpret this clinical finding? A sign of low iron excretion An uncommon benign occurrence An expected occurrence in female newborns The result of a medication administered during labor

An uncommon benign occurrence The brick-red color in the urine is caused by albumin and urates that are found in the first week of life. Iron is eliminated by way of the gastrointestinal tract. The finding is unrelated to the sex of the infant; it is not hormonally based. No medication administered during labor will cause this discoloration.

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?

interruption of the spasm

What does a nurse who is assessing a newborn 3 minutes after birth remember is the range of heart rate for a healthy, alert neonate? 120 and 180 beats/min 130 and 170 beats/min 110 and 160 beats/min 100 and 130 beats/min

110 and 160 beats/min The newborn's heart rate varies with activity; crying can increase it to 180 beats/min, whereas deep sleep may lower it to 80 to 100 beats/min; a rate between 110 and 160 beats/min is the average. A heart rate in an alert, noncrying newborn that is faster than 160 beats/min constitutes tachycardia. The heart rate of an alert, noncrying newborn that is slower than 110 beats/min constitutes bradycardia.

The parents of a neonate born with a cleft lip ask a nurse when the cleft lip will be repaired. What is the best response by the nurse? 1. "When the baby has teeth." 2. "Sometime around 18 months of age." 3. "Usually before the baby is 12 weeks old." 4. "As soon as the baby starts to gain weight."

3. "Usually before the baby is 12 weeks old." Surgery is performed as soon as possible; if the infant is in good health, it may be done right after birth or by 6 to 12 weeks of age. Surgery is performed much earlier than 18 months; babies begin to have teeth at 7 to 8 months of age. Cleft palate, not cleft lip, may be repaired at this time. Healthy newborns lose weight during the first week of life. A decision to perform surgery at birth is not solely predicated on the newborn's weight gain or loss; other factors such as age are also considerations.

A nurse is caring for an infant who has undergone surgery to correct a myelomeningocele. What assessment provides data about a potential major complication for this infant? 1. Daily weights 2. Fluid output every 8 hours 3. Blood pressure every 12 hours 4. Daily head circumference measurements

4. Daily head circumference measurements Hydrocephalus, which typically occurs after surgical correction, is a major complication of myelomeningocele. Measuring the head circumference daily 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.

A 3-month-old infant hospitalized with severe diarrhea has excoriated skin in the diaper area. The parents become concerned when they discover that the nurse has left the infant without a diaper. What is the nurse's explanation for this action? Exposing the excoriated areas helps reduce the fever. Cleansing of the skin followed by air-drying reduces excoriation. Air-drying the perineal area prevents the diaper from sticking to the skin. Leaving the area exposed allows observation of when the infant passes stool.

Cleansing of the skin followed by air-drying reduces excoriation. Air-drying promotes healing; moisture macerates the skin and provides a medium for the growth of microorganisms. There are no data to indicate that the infant has a fever. Preventing the diaper from adhering to the skin is not the reason for exposing the area. Although the nurse can monitor the infant's passage of stool, this is not the reason the area is left exposed.

A 1-day-old infant with an imperforate anus undergoes a pull-through procedure with an anoplasty. What should postoperative nursing care include? Withholding oral feedings for several days Encouraging continuation of breastfeeding Placing the infant in the Trendelenburg position Positioning the infant supine with the head of the crib elevated

Encouraging continuation of breastfeeding The goal is to prevent constipation to limit trauma to the surgical site. Breast milk produces a softer stool. Oral feedings are started soon after surgery. Placing the infant in the Trendelenburg position will not promote healing in the anal area and may impede respiratory excursion. Positioning the infant supine with the head of the crib elevated will increase pressure in the perianal area, which could compromise healing.

A newborn with an anorectal anomaly undergoes anoplasty. At the 2-week follow-up visit, a series of anal dilations is started. What should the nurse recommend to the parents to help prevent the infant from becoming constipated? 1. Use a soy formula. 2. Breastfeed if possible. 3. Administer a suppository nightly. 4. Offer glucose water between feedings.

2. Breastfeed if possible. Human milk has a laxative effect that promotes a soft stool; breastfed infants rarely become constipated. There are no data to indicate that this infant is allergic to milk, so there is no need to use a soy formula at this time. Administering a nightly suppository or offering glucose water between feedings is unnecessary.

The parents of a boy born with hypospadias ask the nurse at what age the repair of this congenital defect is performed. What is the most appropriate response by the nurse? Shortly after birth Between 4 and 5 years of age Just before the onset of puberty After 6 months and before 1 year of age

After 6 months and before 1 year of age During infancy is the preferred age, before the development of body image and fear of castration. The phallus is not developed enough for surgery to be performed shortly after birth. Children 4 to 5 years of age are in the stage of development that is accompanied by fear of mutilation. Having corrective surgery just beyond the onset of puberty is too late. Corrective surgery should be done before the child has to use bathrooms with other boys. The lack of a normal stream of urine can cause psychological and self-esteem issues for a child of this age.

How does a nurse identify possible developmental dysplasia of the hip (DDH) during a newborn assessment? Depressed dance reflex Limited adduction of the leg Asymmetry of the gluteal folds Shortened leg on the unaffected side

Asymmetry of the gluteal folds The gluteal folds should be symmetric, as should all planes and folds of the body. An abnormality of the hips will cause asymmetry, a shorter leg on the affected side, or both. The dance reflex is not affected in DDH. With DDH, abduction of the leg is usually limited at the hip. The leg on the affected, not unaffected, side appears to be shorter with DDH.

A nurse is assessing a newborn born after 32 weeks' gestation. Which clinical finding does the nurse anticipate? Barely visible areola and nipple Zero-degree square window sign Pinnae that spring back when folded Palms and soles with clearly defined creases

Barely visible areola and nipple Breast tissue is not developed or palpable in an infant of less than 33 weeks' gestation. A zero-degree square window sign is present in an infant of 40 to 42 weeks' gestation. The pinnae spring back after being folded in an infant of 36 weeks' gestation. Creases in the palms and on the soles are not clearly defined until after the 37th week of gestation.

A 3-week-old infant is admitted with a tentative diagnosis of hypertrophic pyloric stenosis. Before conducting the admission assessment of the abdomen, the nurse moves the infant's legs in a bicycling-type motion. How does this help the nurse's assessment? Relaxes abdominal muscles Detects weak abdominal muscles Enables palpation of abdominal contour Improves assessment of abdominal rebound

Relaxes abdominal muscles Bicycling increases abdominal relaxation, enabling the examiner to palpate the abdomen easily. Muscular anomalies of the abdomen are detected by means of palpation, but first the abdomen must be relaxed. Abdominal contour is assessed by means of inspection, not palpation; bicycling does not improve its visualization. Abdominal rebound is assessed by means of palpation, but first the abdomen must be relaxed.

phenylketonuria (PKU)

a rare inherited disorder that causes an amino acid called phenylalanine to build up in the body; Without the enzyme necessary to process phenylalanine, a dangerous buildup can develop when a person with PKU eats foods that contain protein or eats aspartame, an artificial sweetener This is a life long disease and this diet must be maintained through the lifespan

The nurse is performing a newborn assessment. Which finding indicates the need for follow-up care? Presence of the Babinski reflex A head circumference of 33 cm 30-degree abduction of the infant's hips An umbilical cord containing three vessels

30-degree abduction of the infant's hips Thirty degrees represents limited hip abduction and is indicative of developmental dysplasia of the hip. The Babinski reflex is an expected newborn finding. A head circumference of 33 cm is an expected measurement for a newborn at term. An umbilical cord with three vessels is an expected finding.

A nurse is obtaining the health history of a 7-month-old who has had repeated episodes of otitis media. What question is most important for the nurse to include in the interview with the mother? "Please describe your child's feeding pattern." "Tell me how often your child has had ear infections." "What medicine do you give your child for the ear infections?" "Do any of your children other than your baby have this problem?"

"Please describe your child's feeding pattern." It is important to determine the infant's feeding pattern, because drinking formula from a bottle while in a recumbent position may lead to pooling of fluid in the pharyngeal cavity, which hinders eustachian tube drainage. Although knowing the frequency of ear infections is important, the factor that precipitated the otitis media is more significant. Although it is important to determine what medication has been given for otitis media, it is more important to determine the cause of this infection. Asking about the other family members is irrelevant, because otitis media is an inflammatory response, not a hereditary disease.

A nurse evaluating a 1-year-old infant's hematocrit reading compares it with the expected hematocrit range for this age group. What is the hematocrit of a healthy 12-month-old infant? 19% to 32% 29% to 41% 37% to 47% 42% to 69%

29% to 41% The expected hematocrit range for a 1-year-old infant is 29% to 41%. A range of 19% to 32% is too low; these readings occur with problems such as prolonged blood loss. A range of 37% to 47% is too high; this is the expected hematocrit range for an adult female. A range of 42% to 69% is too high; this is the expected hematocrit range for a newborn.

A newborn is diagnosed as having neonatal abstinence syndrome (NAS) after exhibiting jitteriness, irritability, and a shrill cry. What is the priority nursing care? Administering an opioid antagonist Limiting fluid intake to inhibit vomiting Assessing for age-appropriate developmental level Reducing environmental stimuli to promote relaxation

Reducing environmental stimuli to promote relaxation The neonate who is withdrawing from opiates is very sensitive to light, noise, and surrounding activity; the infant must be kept calm and comfortable to reduce overreaction to stimuli. Morphine or other opioids are administered to those infants who have loose stools and other gastrointestinal problems resulting from withdrawal. Some of these infants need tranquilizers or sedatives to minimize the effects of withdrawal. An opioid antagonist would lower the seizure threshold and is contraindicated in this clinical situation. Fluid intake must be increased to prevent dehydration in the infant who vomits. Assessment for developmental status is not the priority; physical needs take precedence.

What is the nurse's initial action immediately after assisting with a precipitous birth in the triage area of the emergency department? Warming the newborn Clamping the umbilical cord Assessing maternal bleeding Monitoring expulsion of the placenta

Warming the newborn Immature thermoregulation necessitates warming the newborn to prevent neonatal hypothermia. The cord may be left intact until the newborn's temperature has stabilized, after which it may be clamped. It is too soon to evaluate the hemorrhagic condition of the mother; the placenta has not yet been expelled. The expulsion of the placenta is not a concern; it may not separate for 30 minutes.

The parent of a newborn asks a nurse why, except for hepatitis B vaccine, the immunization schedule does not start until the infant is 2 months old. How should the nurse respond? "A newborn's spleen can't produce efficient antibodies." "Infants younger than 2 months are rarely exposed to infectious disease." "The immunization will attack the infant's immature immune system and cause the disease." "Maternal antibodies interfere with the development of active antibodies by the infant when immunized."

"Maternal antibodies interfere with the development of active antibodies by the infant when immunized." Passive antibodies received from the mother will be diminished by age 8 weeks and will no longer interfere with the development of active immunity to most communicable diseases. The spleen does not produce antibodies. Infants often are exposed to infectious diseases. The viruses in immunizations are inactivated or attenuated; they may cause irritability and fever but will not cause the related disease.

What is the priority nursing intervention for an infant with a myelomeningocele before surgical correction? 1. Minimizing infection 2. Preventing trauma to the sac 3. Monitoring for increasing paralysis 4. Assessing the degree of bowel and bladder control

2. Preventing trauma to the sac A meningomyelocele is thinly covered and fragile. Trauma to the sac can damage functioning neural tissue; an intact sac eliminates a potential portal of entry for microorganisms. Although minimizing infection is extremely important, it is not the priority; care of the sac is even more important, because an intact sac bars entry by microorganisms. Although observation for paralysis is an important nursing measure, it is not the priority. The extent of a meningomyelocele will influence the child's ability to control bowel and bladder function, but control is not developed until the toddler and preschool years.

What should the nurse teach parents about their newborn's diagnosis of phenylketonuria (PKU)? A low-phenylalanine diet is required. Phenylalanine is not necessary for growth. Phenylalanine can be administered to correct the deficiency. A substitute for phenylalanine is an increased amount of other amino acids.

A low-phenylalanine diet is required. Reducing dietary phenylalanine helps prevent brain damage. The PKU diet is planned to maintain the serum phenylalanine level at 2 to 8 mg/100 mL. Phenylalanine is essential for growth and development of the brain. Administering phenylalanine is contraindicated. There is no substitute for phenylalanine, which is one of the essential amino acids.

A nurse is caring for a preterm neonate with physiologic jaundice who requires phototherapy. What is the physiologic mechanism of this therapy? Stimulates the liver to dispose of the bilirubin Breaks down the bilirubin into a conjugated form Facilitates the excretion of bilirubin by activating vitamin K Dissolves the bilirubin, allowing it to be excreted by the skin

Breaks down the bilirubin into a conjugated form Phototherapy changes unconjugated bilirubin in the skin to conjugated bilirubin bound to protein, permitting excretion in the urine and feces. Phototherapy does not affect liver function; the liver does not dispose of bilirubin. Vitamin K is necessary for prothrombin formation, not bilirubin excretion. The bilirubin is not excreted by way of the skin

An infant is born in the breech position, and assessment indicates the presence of Erb palsy (Erb-Duchenne paralysis). Which clinical manifestation supports this conclusion? Inability to turn the head to the unaffected side Absence of the grasp reflex on the affected side Absence of the Moro reflex on the unaffected side Flaccid arm with the elbow extended on the affected side

Flaccid arm with the elbow extended on the affected side With Erb-Duchenne paralysis there is damage to spinal nerves C5 and C6, which causes paralysis of the arm. The grasp reflex is intact, because the fingers usually are not affected; if C8 is injured, paralysis of the hand results (Klumpke paralysis). There would be an absence of the Moro reflex only on the affected side. There is no interference with head turning; usually injury results from excessive lateral flexion of the head as the shoulder is delivered.

What is the nurse's primary critical observation when assessing a newborn for an Apgar score? Heart rate Respiratory rate Presence of meconium Evaluation of the Moro reflex

Heart Rate The heart rate is vital for life and is the most critical observation in Apgar scoring. Respiratory effort rather than rate is included in the Apgar score; the rate is very erratic. Meconium may or may not be present at this time and is not a part of Apgar scoring. Evaluation of the Moro reflex is not a part of Apgar scoring, but this reflex should be assessed later.

A nurse teaches the parents of an infant with a cardiac defect about how to decrease the workload of their baby's heart. What should the teaching plan include? How to organize care to support uninterrupted sleep Reasons that the infant should not be held or cuddled Reasons that a regular feeding schedule should be maintained How to stimulate the infant periodically to promote respiratory excursion

How to organize care to support uninterrupted sleep Long periods of rest must be promoted; activities should be organized to minimize interruptions. Parents should be encouraged to cuddle their infants, both for emotional development and to induce sleep. The feeding plan should be flexible to accommodate the infant's sleep and wake needs and patterns. Stimulation should be minimized to decrease the workload of the heart.

A nurse is caring for an infant with meningitis. When the nurse extends the baby's leg, the hamstring muscles go into spasm and the infant begins to cry. What sign or reflex is the infant exhibiting? Kernig sign Babinski reflex Chvostek sign Cremasteric reflex

Kerning Sign The Kernig sign is indicative of meningitis; it is demonstrated by a spasm of the hamstring muscles when the legs are extended. The Babinski reflex is dorsiflexion and fanning of the toes when the sole is stroked; adults with neuromuscular impairment and healthy infants exhibit this sign. The Chvostek sign is elicited by tapping on the facial nerve in the region of the parotid gland; spasm indicates tetany. In a male, the cremasteric reflex is elicited by stroking the inner thigh; this should cause the testes to retract into the scrotal sac.

A 6-week-old infant has just been found to have gastroesophageal reflux. What teaching is most important to discuss with the parents at this time?

Providing formula thickened with cereal; For some infants the thickened formula decreases the number of vomiting episodes while increasing caloric intake to support adequate growth. Breast milk can be placed in a bottle and thickened with cereal

A nurse weighs a neonate who is born at 29 weeks' gestation. The weight is 3 lb 9 oz (1616 g). In light of this weight and gestational age, how should this infant be classified? Preterm Immature Small for gestational age Appropriate for gestational age

Preterm Preterm describes a neonate born at 37 weeks' gestation or sooner, regardless of weight. There is no classification called immature. Small for gestational age means that the weight is below the 10th percentile at any week of gestation. Although this infant's weight is appropriate for gestational age, the term implies a healthy full-term infant.

A child is admitted to the hospital with pneumonia. What is the priority need that must be included in the nursing plan of care for this child? Rest Exercise Nutrition Elimination

REST Rest reduces the need for oxygen and minimizes metabolic needs during the acute, febrile stage of the disease. The child requiring hospitalization for pneumonia is usually confined to bed and needs to reduce activity to conserve oxygen. Nutrition is not a priority; the child is expected to be anorectic during the febrile phase. Elimination is usually not a problem, except as a result of immobility.

A client has delivered her infant by cesarean birth. The nurse monitors the newborn's respiration closely, because infants born via the cesarean method are prone to atelectasis. Why does this occur? The ribcage is not compressed and released during birth. The sudden temperature change at birth causes aspiration. There is usually oxygen deprivation after a cesarean birth. There is no gravity during the birth to promote drainage from the lungs.

The ribcage is not compressed and released during birth. The release following compression of the chest during a vaginal birth is the mechanism for expansion of the newborn's lungs; because this does not occur during a cesarean birth, lung expansion may be incomplete, and atelectasis may result. Temperature change is not implicated in aspiration. The infant is monitored closely to prevent oxygen deprivation. The newborn's head may be held lower than the chest to allow gravity to promote drainage from the lungs after a cesarean birth.

After a spontaneous vaginal birth, the nurse's first actions are clearing the airway and stimulating the newborn to cry. Which nursing intervention should be implemented next? Checking the heart rate Administering oxygen by mask Performing a complete physical assessment Placing the infant in skin-to-skin contact with the mother

Placing the infant in skin-to-skin with the mother Once the airway has been cleared, the nurse should first dry and place the newborn in a warm environment; skin-to-skin contact with the mother is the best strategy for preventing chilling. Checking the heart rate is done later during the newborn assessment. There are no data to indicate that the newborn requires oxygen. The physical assessment is not the priority at this time; conserving body heat takes precedence.

An infant born at 40 weeks' gestation weighs 6 lb 13 oz (3090 g). What is the nurse's assessment of the neonate? Small for gestational age (SGA) and term SGA and preterm Appropriate for gestational age (AGA) and term AGA and preterm

Appropriate for gestational age (AGA) and term Birth between 38 and 42 weeks' gestation is considered term; at term, healthy neonates weigh between 5 lb 10 oz and 8 lb 6 oz (2551 to 3799 g). Although the birth took place between 38 and 42 weeks' gestation (term infant), an SGA infant weighs less than the expected range for the gestational age. A preterm infant is one born before 38 weeks' gestation; the infant's weight is within the expected range for 40 weeks' gestation. Although the infant's weight is appropriate for the gestational age of 40 weeks, the infant is not preterm, because birth occurred between 38 and 42 weeks' gestation.

A client gives birth to a full-term male with an 8/9 Apgar score. What should the immediate nursing care of this newborn include? Assessing respirations, keeping him warm, and identifying him Applying an antibiotic to the eyes, administering vitamin K, and bathing him Aspirating the oropharynx, rushing him to the nursery, and stimulating him often Weighing him, placing him in a crib, and waiting until the mother is ready to hold him

Assessing respirations, keeping him warm, and identifying him Establishing a patent airway, diminishing cold stress, and identifying the newborn are the priorities. Application of eye prophylaxis and administration of vitamin K are often delayed to allow the parents to bond with the infant; a bath at this time will increase the risk of cold stress. Aspirating the oropharynx, rushing him to the nursery, and stimulating him frequently are measures appropriate for a compromised newborn; an 8/9 Apgar score is indicative of a healthy newborn. Weighing him, placing him in a crib, and waiting until the mother is ready to hold him are not the priority care for a newborn.

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? Diapers should be changed at least every 4 hours. Frequent diaper changes with cleansing are needed. Medicated ointment should be applied six times a day. Powder may be used in the perineal area when it becomes wet.

Frequent diaper changes with cleansing are needed. 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 client at 43 weeks' gestation has just given birth to an infant with typical postmaturity characteristics. Which signs of postmaturity does the nurse identify? Cracked and peeling skin Long scalp hair and fingernails Red, puffy appearance of face and neck Vernix caseosa covering the back and buttocks Creases covering the neonate's full soles and palms

Cracked and peeling skin Long scalp hair and fingernails Creases covering the neonates full soles and plans Dry, peeling skin is related to decreased vernix and prolonged immersion in amniotic fluid. Abundant scalp hair and long fingernails are characteristics of postmaturity. These findings are typically noted in a term newborn who is 2 to 3 weeks old. Creases on the entire soles and palms are typical of full-term maturity; preterm newborns have few sole and palm creases. A red, puffy appearance of the face and neck is not a sign of postmaturity; neonates born to diabetic mothers usually have this appearance. Vernix is found on a newborn at about 38 weeks' gestation and disappears after 40 weeks' gestation.

A nurse is discussing areas of potential concern, such as anemia, with several parents of 6-month-old infants. What should the nurse tell them is the most common cause of anemia in 1-year-olds?

Iron deficiency Breast milk and unfortified infant formulas increase the risk for iron-deficiency anemia in infants. Cow's milk, which is introduced at 1 year of age, is also low in iron and may cause iron-deficiency anemia unless iron supplements or iron-rich solid foods are added to the diet. Thalassemia is a genetic disease that affects specific populations and is not a common disorder. Lead poisoning usually occurs in children older than 1 year, and its prevalence is less than that of iron-deficiency anemia. Sickle cell anemia is a genetic disease that affects specific populations and is not as common as iron-deficiency anemia.

Immediately after birth, a newborn and mother were given the opportunity to bond. Now, on admission to the newborn nursery, it is noted that the infant has signs of respiratory distress, and transient tachypnea of the newborn is suspected. The nurse reviews the mother's obstetric history and takes the neonate's vital signs. In light of this information and the nursery routine, what is the most appropriate intervention by the nurse for this newborn?. Feed glucose water. Bathe with mild soap. Keep in overbed warmer. Take to mother's bedside for further bonding.

Keep in overbed warmer The newborn should remain in the nursery under the overbed warmer for continued observation because tachypnea is present. Newborns with respiratory rates faster than 60 breaths/min should not be fed, because there is a risk for aspiration. Bathing will stress the newborn further and should be avoided. This newborn should not leave the close observation of the newborn nursery.

On admission to the nursery a newborn is found to be experiencing cold stress. What is the nurse's immediate goal at this time? Minimize shivering Prevent hyperglycemia Limit oxygen consumption Prevent metabolism of fat stores

Prevent metabolism of fat stores If the newborn is cold there is increased brown fat metabolism (nonshivering thermogenesis), which increases levels of fatty acids in the blood, predisposing the infant to acidosis. Newborns do not shiver. Hypoglycemia, not hyperglycemia, may occur because the newborn's glycogen reserves are depleted rapidly when under stress. Although oxygen consumption increases during cold stress, limiting oxygen consumption is not the priority; increased fat metabolism is more serious.

A nurse is teaching a parent about the immunization schedule for babies. Between which months of age should the measles vaccine be given? 2 and 5 6 and 8 9 and 11 12 and 15

12 and 15 Between 12 and 15 months is the optimal age because maternal antibodies to measles are no longer present to block the formation of the child's own antibodies. The measles vaccine is not given between 2 and 5 months, between 6 and 8 months, or between 9 and 11 months because of the questionable efficacy of the vaccination, due to the presence of maternal antibodies.

An infant with talipes equinovarus has a plaster cast applied to the involved foot. How should the nurse move the infant while the cast is wet?

By handling the cast with just the palms; The palm provides a wide base of support for the infant's body and the casted extremity. Touching the cast with the fingertips will cause indentations that may create pressure points; this may compromise the skin, neurovascular function, or both. The cast must be touched because the lower extremity and the cast must be supported.

An infant is receiving the first diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) at 2 months of age. What instructions should the nurse give the parents? Give the baby aspirin if there is pain. Call the clinic if marked drowsiness occurs. Apply ice to the injection site if there is swelling. Provide heat at the injection site if redness occurs.

Call the clinic if marked drowsiness occurs. Altered level of consciousness and seizures are rare but serious complications of the pertussis vaccine. Aspirin should not be given to infants and children because it is associated with Reye syndrome, and the nurse is not legally allowed to prescribe medications anyway. Infants are sensitive to the application of ice. Heat will cause an extension of the inflammatory response and should be avoided.

Hydramnios is diagnosed in a primigravida at 35 weeks' gestation. For what condition should the nurse assess the newborn? Cardiac defect Kidney disorder Diabetes mellitus Esophageal atresia

Esophageal atresia Esophageal atresia is associated with hydramnios. There is usually a history of polyhydramnios because the fetus in unable to swallow the amniotic fluid. Cardiac defects are not associated with hydramnios. Kidney disorders are associated with oligohydramnios, not hydramnios. Diabetes in the newborn is not associated with hydramnios.

The nurse is caring for the newborn of a mother with diabetes. For which signs of hypoglycemia should the nurse assess the newborn? Pallor Irritability Hypotonia Ineffective sucking Excessive birth weight

Irritability Hypotonia Ineffective Sucking An inadequate amount of cerebral glucose causes irritability and restlessness. Hypoglycemia affects the central and peripheral nervous systems, resulting in hypotonia. Feeding difficulties result from hypoglycemic effects on the fetal central nervous system. Hypoglycemia causes cyanosis, not pallor, in the newborn. Excessive birthweight is common but does not indicate hypoglycemia.

While assessing a newborn the nurse notes the following findings: arms and legs slightly flexed; smooth, transparent skin; abundant lanugo on the back; slow recoil of the pinnae; and few sole creases. What complication does the nurse anticipate in light of these findings? Polycythemia Hyperglycemia Postmaturity syndrome Respiratory distress syndrome

Respiratory distress syndrome The assessment findings are indicative of a preterm infant; therefore the nurse should monitor the infant for signs of respiratory distress syndrome. Polycythemia may develop in a preterm large-for-gestational-age (LGA) infant; however, there are no data to indicate that the infant is LGA. Preterm infants may become hypoglycemic, not hyperglycemic. The neonate is preterm, not postterm.

A nurse in the pediatric clinic receives a call from the mother of a 12-month-old infant who has had a fever, runny nose, cough, and white spots in the mouth for 3 days. A rash started on the face and has now spread to the entire body. Which communicable infection does the nurse suspect? Rubella Rubeola Pertussis Varicella

Rubeola White spots (Koplik spots) and the rash with a mucous discharge from the nose (coryza) are clinical indicators of rubeola (measles). Rubella (German measles), pertussis (whooping cough), and varicella (chickenpox) do not cause Koplik spots.

Because preterm infants are at risk for respiratory distress syndrome, immediate nursing intervention is required when a preterm infant exhibits what sign? Expiratory grunting Substernal retractions Tachycardia of 160 beats/min Respirations of 50 to 60 breaths/min

Substernal retractions Substernal retractions are a prominent feature of respiratory problems in preterm infants because of their compliant chest walls. Expiratory grunting is more indicative of low body temperature, not respiratory distress, in a preterm infant. Tachycardia of 160 beats/min is within the expected range of 110 to 160 beats/min. A rapid respiratory rate of 40 to 60 breaths/min is expected in neonates.

A nurse teaches a couple about care of their newborn, who has been circumcised. The nurse concludes that the teaching is effective when the father says what? "We shouldn't expect fussy behavior." "We should leave the baby undiapered." "We should apply petrolatum gauze to the penis." "We should notify the clinic if we see a yellow discharge."

"We should apply petrolatum gauze to the penis." Petrolatum gauze helps control bleeding and prevents adherence to the diaper. Fussy behavior is expected for a few hours after the procedure. Leaving the baby undiapered is not practical with a male infant. Yellow exudate is expected; it is not a sign of an infectious process.

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. Moist sterile dressing 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.

An infant who has a congenital heart defect with left-to-right shunting of blood is admitted to the pediatric unit. What early sign of heart failure should the nurse identify? 1. Cyanosis 2. Restlessness 3. Decreased Heart Rate 4. Increased Respiratory Rate

4. Increased Respiratory Rate Because the lungs are stressed by pulmonary edema, a quicker respiratory rate is the first and most reliable indicator of early heart failure in infants. Cyanosis is a late sign of heart failure; with early failure there is still adequate perfusion of blood. Infants with early heart failure do not move about; they become fatigued quickly, especially when feeding, because of a decrease of oxygen to body cells. The heart rate of an infant in early heart failure increases, not decreases, in an attempt to increase oxygen to body cells.

After a difficult vaginal birth, assessment of a full-term newborn reveals an unequal Moro reflex on one side and a flaccid arm in adduction. Which problem does the nurse suspect? Brachial palsy Supratentorial tear Fracture of the clavicle Developmental dysplasia of the hip

Brachial palsy Brachial palsy results from excessive stretching of the nerve fibers that run from the neck, through the shoulder, and down toward the arm; the muscles of the upper arm are involved, and the infant holds the arm at the side with the elbow extended and the hand rotated inward. Signs of a central nervous system disturbance will be present with a supratentorial tear. Signs of dislocation and evidence of pain are noted with a fractured clavicle. Developmental dysplasia of the hip is diagnosed with other clinical findings, such as unequal gluteal folds and the Ortolani sign.

A small-for-gestational-age (SGA) newborn who has just been admitted to the nursery has a high-pitched cry, appears jittery, and exhibits irregular respirations. What complication does the nurse suspect? Hypovolemia Hypoglycemia Hypercalcemia Hypothyroidism

Hypoglycemia

During the assessment of a preterm neonate the nurse determines that the infant is experiencing hypothermia. Which action should the nurse take? Rewarm gradually Notify the practitioner Assess for hyperglycemia Record skin temperature hourly

Rewarm gradually Gradually rewarming an infant experiencing cold stress is essential to avoid compromising the infant's cardiopulmonary status. It is not necessary to notify the practitioner initially. It is the nurse's responsibility to rewarm the infant. An infant experiencing cold stress will become hypoglycemic because glycogen and glucose are metabolized to maintain the core temperature. Skin temperature should be taken at least every 15 minutes until stable.

An infant who has undergone surgery for hypertrophic pyloric stenosis (HPS) is being bottle fed by the mother. What should the nurse teach the mother about feedings to decrease the chance of the infant vomiting? Start with small, frequent feedings. Rock for 20 minutes after a feeding. Keep the infant awake for 30 minutes after feeding. Position the infant flat on the right side during feedings.

Start with small, frequent feedings. Starting with small feedings will decrease the risk of vomiting. Rocking, keeping the infant awake, and positioning the infant horizontally all increase the chance of vomiting.

A male newborn has been exposed to human immunodeficiency virus (HIV) in utero. Which assessment supports the diagnosis of HIV infection in the newborn? Delay in temperature regulation Continued bleeding after circumcision Hypoglycemia within the first day of birth Thrush that does not respond readily to treatment

Thrush that does not respond readily to treatment Thrush, an oral infection caused by Candida albicans, is an opportunistic infection that may be indicative of underlying HIV infection. A delay in temperature regulation is more commonly associated with immaturity of the hypothalamus. Bleeding after a circumcision is associated with a bleeding disorder such as hemophilia. Hypoglycemia is usually associated with the infant of a diabetic mother.

On the third postpartum day a mother visits the clinic and asks why her newborn's skin has begun to appear yellow. What does the nurse explain is the cause of her infant's change in skin tone? Breast milk ingestion Inadequate fluid intake Immaturity of the vascular system Breakdown of fetal red blood cells

Breakdown of fetal red blood cells Physiological jaundice is caused by an increased bilirubin level, a result of the breakdown of fetal red blood cells, which the immature liver cannot conjugate rapidly enough for excretion; this occurs on the second or third day of life. Breast milk jaundice does not occur until the fifth or sixth postpartum day; it is caused by a factor in the breast milk that inhibits conjugation of bilirubin. Inadequate fluid intake is evidenced by a decreased urinary output and depressed fontanels. Mottling in the newborn is related to an immature vascular system.

The mother of an 11-month-old infant who just underwent surgery to create a temporary colostomy is concerned about care at home. What instructions about care of the colostomy should the nurse include in the teaching plan? Empty and rinse the bag whenever necessary. Limit diarrhea by restricting milk and milk products. Irrigate the colostomy with as much water as possible. Report slight bleeding from the stoma site immediately.

Empty and rinse the bag whenever necessary. Keeping the bag clean limits odor and promotes cleanliness. The part of the drainage appliance that is attached to the skin is not removed routinely, only when the integrity of its adherence to the skin is compromised. Milk and milk products do not have to be limited. Only 50 to 100 mL of saline solution should be used for irrigation to prevent fluid reabsorption and retention. Slight bleeding is expected in the immediate postoperative period; it should be reported on the next routine visit.

What should the nurse's initial discussion include to best assist new parents in understanding the unique characteristics of their newborn? Auditory and visual acuity Expected movements and behaviors The need for parent-infant attachment The need to establish a feeding schedule

Expected movements and behaviors Information on typical behaviors helps parents understand the unique features of their newborn and promotes interaction and appropriate care. A discussion of auditory and visual acuity is too limited; the parents need a broader discussion of infant behaviors. Although parent-infant attachment is important, this can best be fostered if parents know what behaviors to expect from their infant. The need to establish a feeding schedule is too limited; in addition, most infants are on a demand feeding schedule, which fosters individuality.

A preterm neonate admitted to the neonatal intensive care nursery exhibits muscle twitching; seizures; cyanosis; abnormal respirations; and a short, shrill cry. Which complication does the nurse suspect? Tetany Spina bifida Hyperkalemia Intracranial hemorrhage

Intracranial hemorrhage Intracranial bleeding may occur in the subdural, subarachnoid, or intraventricular spaces of the brain, causing pressure on vital centers; clinical signs are related to the area and degree of cerebral involvement. Tetany is caused by hypocalcemia; it is manifested by exaggerated muscle twitching. Spina bifida is a defect of the spinal column that is observed at birth. An increased potassium level causes cardiac irregularities, not the irritable behavior observable with central nervous system involvement.

The nurse is caring for a 1-hour-old newborn. Which assessment characteristics represent a preterm gestational age? Skin: thin, veins visible; breasts: flat areolae, no buds; plantar creases: absent; lanugo: abundant Skin: parchment/wrinkled; breasts: flat areolae, no buds; plantar creases: cover entire sole; lanugo: absent Skin: thin, veins visible; breasts: flat areolae, no buds; plantar creases: covering the entire sole; lanugo: abundant Skin: cracking/few veins; breasts: raised areolae (3- to 4-mm buds); plantar creases: covering the anterior two thirds of the sole; lanugo: thinning

Skin: thin, veins visible; breasts: flat areolae, no buds; plantar creases: absent; lanugo: abundant The characteristics of preterm, term, and postterm gestational age are based on assessments of physical maturity such as the Ballard or Dubowitz assessment. A preterm infant's skin is translucent, with many visible veins. A term infant has some cracking of the skin and some visible veins, depending on gestational age. Term is any gestation after 38 weeks; veins are less visible at 40 weeks' gestation. The postterm infant typically has dry, leathery, parchmentlike skin with numerous deep wrinkles. The areolae of a preterm infant are flat, without buds, and they become more raised during development, averaging 3 to 4 mm at term and 5 to 10 mm in the postterm infant. The plantar creases develop on the foot during gestation, beginning smooth, then covering two thirds at term, and finally covering the entire sole after term. Lanugo is the fine downy hair that diminishes as the infant develops gestationally.

Continuous positive-pressure ventilation therapy by way of an endotracheal tube is started in a newborn with respiratory distress syndrome (RDS). The nurse determines that the infant's breath sounds on the right side are diminished and that the point of maximum impulse (PMI) of the heartbeat is in the left axillary line. How should the nurse interpret these data? These findings are expected because infants with this disorder often have some degree of atelectasis. The inspiratory pressure on the ventilator is probably too low and needs to be increased for adequate ventilation. These findings indicate that the infant may have a pneumothorax and that the health care provider should be contacted immediately. The endotracheal tube needs to be pulled back to ventilate both lungs because it has probably slipped into the left main stem bronchus.

These findings indicate that the infant may have a pneumothorax and that the health care provider should be contacted immediately. Diminution of breath sounds on the right side and detection of PMI in the left axillary line are key signs of a pneumothorax, which can occur when an infant is being given oxygen by means of positive pressure. These findings are not expected in infants with RDS. A problem with the ventilator will not result in these clinical manifestations. These findings do not indicate that the endotracheal tube has moved.

When explaining the occurrence of febrile seizures to a parents' class, what information should the nurse include? They may occur in minor illnesses. The cause is usually readily identified. They usually do not occur during the toddler years. The frequency of occurrence is greater in females than males.

They may occur in minor illnesses. Febrile seizures are usually not associated with major neurologic problems. Between 95% and 98% of these children do not experience epilepsy or other neurologic problems. The cause of febrile seizures is still uncertain. Most febrile seizures occur after 6 months of age and before age 3 years, with the average age of onset between 18 and 22 months. Boys are affected about twice as frequently as girls

After surgery for a myelomeningocele, an infant is being fed by means of gavage. When checking placement of the feeding tube, the nurse is unable to hear the air injected because of noisy breath sounds. What should the nurse do next? Notify the provider. Advance the tube 1 cm. Insert 1 mL of formula slowly. Try aspirating stomach contents.

Try aspirating stomach contents. Gastric returns indicate correct placement of the feeding tube. Further assessment is necessary before the provider is notified. Advancing the tube even 1 cm may cause undue trauma, regardless of where the tube is located. Inserting even a small amount of formula is unsafe until correct placement is verified; formula may enter the lungs if the tube is not in the stomach.

Supplemental oxygen is ordered for a preterm neonate with respiratory distress syndrome (RDS). What action does the nurse take to reduce the possibility of retinopathy of prematurity? Humidifying oxygen flow to prevent dehydration Uncovering the entire body to increase exposure to the oxygen Applying eye patches to both eyes to protect them from the oxygen Verifying oxygen saturation frequently to adjust flow on the basis of need

Verifying oxygen saturation frequently to adjust flow on the basis of need Determining oxygen saturation identifies the need for oxygen supplementation; prolonged use of oxygen concentrations exceeding those required to maintain adequate oxygenation contributes to the occurrence of retinopathy of prematurity. Preventing dehydration by humidifying the oxygen will not prevent retinopathy of prematurity. The skin does not absorb oxygen; it must enter the lungs through inhalation. Retinopathy of prematurity is caused by a high blood concentration of oxygen, not by exposure of the eyes to oxygen.

The parents of a 4-month-old infant with a diagnosis of acute otitis media and fever ask the nurse about the use of antibiotics to treat this condition. What is the best response by the nurse? "Antiinflammatory medications are recommended for this condition." "Typically antiviral medications are given to treat acute otitis media." "Current practice is to wait 72 hours to see whether the condition resolves." "Antibiotics are recommended for infants younger than 6 months with acute otitis media."

"Antibiotics are recommended for infants younger than 6 months with acute otitis media." All cases of acute otitis media (AOM) in infants younger than 6 months should be treated with antibiotics because of their immature immune systems and the potential for infection with bacteria. Current literature indicates that waiting up to 72 hours for spontaneous resolution is safe and appropriate management of AOM in healthy infants older than 6 months and children. However, the watchful waiting approach is not recommended for children younger than 2 years of age who have persistent acute symptoms of fever and severe ear pain. Antiviral or antiinflammatory medications would not be recommended in an acute case of otitis media.

A nurse teaches a new mother about neonatal weight loss in the first 3 days of life. How does the nurse explain the cause of this weight loss? An allergy to formula A hypoglycemic response Ineffective feeding techniques Excretion of accumulated excess fluids

Excretion of accumulated excess fluids Early weight loss occurs because excess fluid is lost, not body mass. Weight loss is expected; there are no data to support an allergic response. Weight loss is not related to hypoglycemia. Neither breast nor formula feeding will prevent the 10% weight loss that is expected in the first few days of life.

What feeding instruction should a nurse give the parent of a 2-month-old infant with the diagnosis of heart failure? 1. Use double-strength formula. 2. Avoid using a preemie nipple. 3. Refrain from feeding until crying from hunger begins. 4. Feed slowly while allowing time for adequate periods of rest.

4. Feed slowly while allowing time for adequate periods of rest. Because of limited exercise tolerance and fatigue, infants with heart failure become too tired to feed; allowing rest and feeding slowly limit the fatigue associated with feeding. Although the infant may be given a formula with a higher caloric value (30 kcal/oz (30 kcal/30 mL) rather than 20 kcal/oz (20 kcal/30 mL)), double-strength formula is too high an osmotic load for the infant. A soft nipple used for preterm infants or a regular nipple with an enlarged opening is preferred to conserve the energy required for sucking. Crying consumes energy and is exhausting. The infant should be fed when exhibiting signs of hunger, such as sucking on a fist.

What is an appropriate nursing intervention for a neonate with respiratory distress syndrome (RDS)? Avoid handling the infant to conserve energy Position the infant to promote respiratory efforts Assess the infant for congenital birth defects to enable early treatment Set the incubator thermostat 10° F (12° C) below body temperature to prevent shivering

Position the infant to promote respiratory efforts Positioning the infant with the head slightly hyperextended and changing the position every 1 to 2 hours helps respiratory secretions drain; this will increase oxygenation by enhancing respiratory efforts. Extensive handling is not desired, but infants do need to be touched. All newborns are assessed for congenital birth defects, not just those with RDS. Ten degrees (12 degrees) below body temperature is too low; it may exacerbate the respiratory distress.

What should the nurse explain to the parents of a newborn with developmental dysplasia of the hip (DDH) will most likely will be part of the infant's treatment? A fitted Pavlik harness Tight swaddling in blankets Periodic strapping to a cradleboard Placement in an infant seat on a set schedule

A fitted Pavlik harness The Pavlik harness promotes hip abduction and flexion. Swaddling or strapping the infant to a cradleboard limits hip abduction and puts stress on the hip joint. Although placing the infant in an infant seat allows movement in the flexed position, it does not promote abduction.

A nurse is assessing an infant with suspected developmental dysplasia of the hip. What does the nurse expect the infant's orthopedic status to reveal? Apparent shortening of one leg Limited ability to adduct the affected leg Narrowing of the perineum with an anal stricture Inability to palpate movement of the femoral head

Apparent shortening of one leg The affected leg appears to be shorter because the femoral head is displaced upward. The infant's ability to abduct, not adduct, the affected leg is affected. An anal stricture is not expected with developmental dysplasia of the hip. When the femoral head slips out of the acetabulum, it is easily palpable.

A preterm infant with respiratory distress syndrome (RDS) has blood drawn for an arterial blood gas analysis. Which test result should the nurse anticipate for this infant? Increased Po 2 Lowered HCO 3 Decreased Pco 2 Decreased blood pH

Decreased blood pH In addition to increased Pco 2, hypoxia from inadequate oxygen/carbon dioxide exchange leads to anaerobic metabolism with an accumulation of acid by-products; both lower blood pH. Po 2 is decreased, because inadequate lung surface area is available for diffusion of gases. Acidosis, not alkalosis, is present; bicarbonate will be normal or increased in the body's attempt to compensate. Pco 2 increases, because inadequate lung surface area is available for the diffusion of gases.

After a difficult birth, a neonate has an Apgar score of 4 after 1 minute. Which sign met the criterion of 2 points? Color: pale Respiratory rate: slow Reflex irritability: grimace Heart rate: 100 beats/min

Heart rate: 100 beats/min A heart rate of 100 beats/min or more is the only criterion that rates a 2 on the Apgar score. The pale color rates a 0. A slow respiratory rate or a weak cry rates a 1. A grimace after testing of reflex irritability rates a 1

Six weeks after birth an infant is found to have developmental dysplasia of the hip. The nurse explains to the parents the benefits of early treatment. What is the rationale for the immediate institution of corrective measures? Mobility will be delayed if correction is postponed. Traction is effective if it is used before toddlerhood. Infants are easier to manage in spica casts than are toddlers. Infants' cartilaginous hip joints promote molding of the acetabulum.

Infants' cartilaginous hip joints promote molding of the acetabulum. The cartilaginous hip joints are the basis for the use of abduction devices (e.g., Pavlik harness) and spica casts when the infant is very young. Congenital hip dysplasia does not limit ambulation for the young child, although the gait will be affected. Traction is not used to correct developmental dysplasia of the hip. Although casted infants are easier to manage than casted toddlers, this is not the reason for early treatment.

What characteristics does a nurse expect infants and young children with failure to thrive to exhibit? Hyperactivity Language deficit Being overweight Tendency to illness Responsiveness to stimuli

Language Deficit Tendency to Illness Language-deficient children usually have developmental delays, including language, motor, social, and adaptive deficits. Infants with failure to thrive are usually frail and are at risk for physical and emotional illnesses. Infants with failure to thrive are usually quiet and lethargic. Being overweight is usually below the fifth percentile of infants with failure to thrive. Responsiveness to stimuli is limited or nonexistent.

During a newborn assessment the nurse identifies the absence of the red reflex in the eyes. What should the nurse's next action be? Rinse the eyes with sterile saline Notify the primary healthcare provider Expect edema to subside within a few days Conclude that this is a result of the prescribed eye prophylaxis

Notify the primary healthcare provider An absence of the red reflex may be indicative of congenital cataracts. The red reflex is elicited by shining the light of an ophthalmoscope into the newborn's eyes, which should produce a reddish circle. Rinsing the eyes will not affect the red reflex. The red reflex or its absence is not related to edema, which may occur after eye prophylaxis, or to eye prophylaxis itself.

During a parenting class a nurse is discussing infant/toddler nutrition and ways to reduce the risk of food allergies. What food item should the nurse recommend that the parents avoid until their children are 3 years old? Cow's milk Soy products Peanut butter Chocolate candy

Peanut Butter Peanut allergies tend to be very severe. To reduce the risk of peanut allergies, parents should delay their introduction into the diet until the gastrointestinal tract has matured. Cow's milk is introduced after 1 year. Although often considered hypoallergenic, soy products can cause food allergies. However, because of the infrequency of soy in the American diet, its entry is not delayed after the first year. Chocolate may be introduced after the first year of life.

Which activities should the nurse expect to see exhibited by a healthy 6-month-old infant during an evaluation of the infant's growth and development?

Playing peek-a-boo Turning completely over Reaching to be picked up Sitting for a short time without support

What should the nursing care of an 8-month-old infant with tetralogy of Fallot include? Restriction of fluid intake to conserve energy Provision of iron-fortified formula to prevent anemia Administration of coagulants to control bleeding tendencies Prevention of increased respiratory effort to promote oxygenation

Prevention of increased respiratory effort to promote oxygenation 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 newborn has just been admitted to the pediatric surgical unit from the birth hospital with a diagnosis of tracheoesophageal fistula. In what position should this child be maintained? Prone, to reduce risk of aspiration Trendelenburg, to drain stomach contents Semi-Fowler, to reduce the risk of chemical pneumonia Supine, to reduce the risk of sudden infant death syndrome

Semi-Fowler, to reduce the risk of chemical pneumonia Because of the connection between the lower esophagus and the trachea, this child is maintained in a semi- to high Fowler position to reduce the risk of acidic stomach contents entering the trachea and causing inflammation of the lung tissues. Vomiting may or may not occur with this type of defect, because the esophagus does connect to the stomach. The semi-Fowler position would be more effective than the prone position in reducing aspiration.

A nurse who is assessing a full-term newborn elicits the Moro reflex. Which method would the nurse utilize to best elicit this reflex? Touching the infant's cheek Striking the surface of the infant's crib suddenly Allowing the infant's feet to touch the surface of the crib Stroking the sole of the foot along the outer edge from the heel to the toe

Striking the surface of the infant's crib suddenly Jarring the crib produces a startle response ( Moro reflex); the legs and arms extend, and the fingers fan out, while the thumb and forefinger form a C. When the cheek is touched, the head turns toward the side that was touched; this is the rooting reflex. When the feet touch the crib surface the stepping reflex is elicited; one foot is placed before the other in a simulated walk with the weight on the toes. When the bottom of the foot is stroked along the outer edge of the sole from the heel to the toe, the toes flare out. This is the Babinski reflex, which is expected because of the newborn's immature nervous system. In an adult, this reflex is a sign of neurological damage.

During a vertex vaginal birth the nurse notes meconium-stained amniotic fluid. What is the priority nursing intervention for the newborn? Stimulating crying Suctioning the airway Using an Ambu bag with oxygen support Placing the infant in the reverse Trendelenburg position

Suctioning the airway Suctioning must be done to minimize the possibility of the aspiration of meconium into the lungs. If the newborn cries before being suctioned, meconium may be aspirated. If the newborn is bagged, any meconium present will be forced into the lungs. If the newborn is positioned in reverse Trendelenburg, meconium may be aspirated.

After surgery for repair of a myelomeningocele, the nurse places the infant in a side-lying position with the head slightly elevated. What is the main reason the nurse places the infant in this position after this particular surgery? To prevent aspiration To promote respiration To reduce intracranial pressure To maintain cleanliness of the suture site

To reduce intracranial pressure The side-lying position with the head slightly elevated promotes venous return by gravity, which helps reduce intracranial pressure, a problem after myelomeningocele repair. Although preventing aspiration, promoting respiration, and maintaining cleanliness of the suture line are all important, the reason for this position that is unique with this type of surgery is that it minimizes intracranial pressure.

A nurse teaches the parents of a 1-year-old infant that the primary developmental milestone to be accomplished between 12 and 15 months of age is which ability? Walk erect Climb stairs Use a spoon Say simple words

Walk erect Walking is the primary developmental milestone for this age group; 1-year-olds are capable of the balance and agility required for walking. A child learns to climb stairs around 15 to 18 months of age. The ability to use a spoon is not developed until 18 months of age. Speaking is not the priority at this age

A nurse is assessing a newborn with suspected retention of a fetal structure that will result in a congenital heart defect. Which fetal structures should undergo change after birth? Mitral valve Foramen ovale Pulmonary veins Ductus arteriosus Pulmonary arteries

Foramen ovale Ductus arteries If the foramen ovale fails to close, the infant will have an atrial septal defect. If the ductus arteriosus fails to close, the pressure in the lungs and heart will be abnormal, resulting in chronic heart disease. The mitral valve, pulmonary veins, and pulmonary arteries do not change after birth.

A client asks the nurse what advantage breast-feeding holds over formula feeding. What major group of substances in human milk are of special importance to the newborn and cannot be reproduced in a bottle formula? Amino acids Gamma globulins Essential electrolytes Complex carbohydrates

Gamma globulins The antibodies in human milk provide the infant with immunity against all or most of the pathogens that the mother has encountered. Amino acids and essential electrolytes are present in commercial formulas. Complex carbohydrates are not required by the infant.

A nurse administers the first series of immunizations to a 2-month-old infant. The nurse tells the mother that if the site becomes inflamed, she should give the prescribed acetaminophen (Tylenol). What else should the nurse instruct the mother to do? Place a warm compress on the area. Put a witch hazel compress on the site. Give a cool sponge bath for 15 minutes. Apply an ice pack to the area for 2 minutes.

Place a warm compress on the area. A warm compress will promote circulation, reduce swelling, and relax muscles, thereby easing the inflammation. Witch hazel will not ease inflammation or promote muscle relaxation. Fever is not an expected response; therefore the cooling effect of a sponge bath is not necessary. The application of cold will not provide relief because it reduces circulation to the area.

A nurse is assessing a newborn with a myelomeningocele. What clinical findings prompt the nurse to suspect hydrocephalus? Tense fontanels High-pitched crying Apgar score of less than 5 A defect in the lumbosacral area Head circumference 2 cm greater than the chest circumference

Tense fontanels High-pitched crying A defect in the lumbosacral area An excessive amount of cerebrospinal fluid associated with hydrocephalus causes tense fontanels. A shrill, high-pitched cry often accompanies progressive hydrocephalus and other neurologic problems. Hydrocephalus complicates approximately 80% of lumbosacral meningomyeloceles. Infants with hydrocephalus may or may not have low Apgar scores. Head circumference 2 cm greater than the chest circumference is expected in a newborn.

The nurse knows that additional discharge instructions are needed for parents whose infant has just undergone corrective surgery for cleft palate when the parent makes what statement? "We need to schedule regular hearing tests, even at this young age." "Lying on the abdomen is prohibited, so we'll keep him in an infant seat." "We know that some difficulty breathing is expected, so we'll position him upright." "We'll use the elbow restraints you provided to keep him from putting his hands in his mouth."

"Lying on the abdomen is prohibited, so we'll keep him in an infant seat." After cleft palate repair the child is allowed to lie on the abdomen, especially immediately after surgery; this will allow drainage of secretions from the mouth. Children with cleft palate have an increased risk of middle ear infections, which can result in hearing loss, so hearing tests are scheduled early and repeated periodically throughout childhood. Until the infant adjusts to breathing through the mouth, he may exhibit difficulty breathing after surgery; this seldom requires more than positioning and support. Elbow restraints may be prescribed to keep the child's hands out of his mouth.

The parents of an infant who is to undergo insertion of a right ventriculoperitoneal shunt for hydrocephalus are taught about postoperative positioning that helps prevent pressure on the valve site. What statement indicates that they understand the teaching? "We'll place her in the position that seems comfortable." "The flat left side-lying position is the safest position for our baby." "We should place her on her back with a small support under the neck." "The right side-lying position with the head supported is the best position."

"The flat left side-lying position is the safest position for our baby." The side-lying position on the unaffected side helps prevent pressure against the valve; the flat position prevents too-rapid drainage of cerebrospinal fluid. Stating that they will place the baby in a comfortable position is inappropriate in the immediate postoperative period; the infant should be kept flat and off the affected side. Neck supports should not be used with infants; they may cause airway occlusion. The right side-lying position in this case puts the infant on the affected side, resulting in pressure on the valve that could cause it to close; this would heighten the risk for increased intracranial pressure.

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? Use a forward-facing infant car seat. Secure the infant seat so that it faces the rear. Position the seat between the driver's and passenger's seats in the front seat. Follow the manufacturer's directions to secure the infant seat in the back seat. Be sure to follow weight guidelines set forth in the manufacturer's instructions.

1. Secure the infant seat so that it faces the rear. 2. Follow the manufacturer's directions to secure the infant seat in the back seat. 3. Be sure to follow weight guidelines set forth in the manufacturer's instructions. 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.

A nurse is assessing a 3-week-old infant who has been admitted to the pediatric unit with hydrocephalus. What finding denotes a complication requiring immediate attention? 1. Tense anterior fontanel 2. Uncoordinated eye/muscle movement 3. Larger head circumference than chest circumference 4. Inability to support the head while in the prone position

1. Tense anterior fontanel A tense or bulging fontanel is indicative of increased intracranial pressure, which is caused by the fluid accumulation associated with hydrocephalus. Conjugate gaze does not occur until 3 to 4 months of age, once the eye muscles have matured. The head is the largest part of the body at this age; the head circumference should be about 1 inch (2.5 centimeters) larger than chest circumference. An infant cannot support the head before 1 to 1½ months of age.

A nurse is assessing a 1-year-old infant. What behavior does the nurse expect to observe? Jumps with both feet Tries to ascend stairs Explores away from the parent Communicates in simple sentences Builds a tower consisting of several blocks

1. Tries to ascend stairs 2. Explores away from the parents A 1-year-old child has the physical ability to attempt to climb stairs. A 1-year-old child may still have some stranger anxiety but will begin to wander away from a parent and explore the environment. Jumping with both feet is beyond the ability of a 1-year-old child; a 15-month-old child can jump with both feet but may fall. A 1-year-old child's vocabulary is limited to one word at a time. Building a tower consisting of several blocks is beyond the ability of a 1-year-old child.

Before administering a nasogastric feeding to a preterm infant, the nurse aspirates a small amount of residual fluid from the stomach. What is the nurse's next action? 1. Returning the aspirate and withholding the feeding 2. Discarding the aspirate and administering the full feeding 3. Returning the aspirate and subtracting the amount of the aspirate from the feeding 4. Discarding the aspirate and adding an equal amount of normal saline solution to the feeding

3. Returning the aspirate and subtracting the amount of the aspirate from the feeding The aspirate should be returned to ensure that the gastric enzymes and acid-base balance are maintained. The amount of the aspirate returned should be subtracted from the volume to be administered in the next feeding. Withholding the feeding will compromise the infant's fluid and electrolyte balance, as will discarding the aspirate from the full feeding. Discarding the aspirate and adding an equal amount of normal saline solution to the feeding will compromise the infant's fluid and electrolyte balance.

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. Sudden absence of breath sounds 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. The toes, when compressed, exhibit a quick return of circulation. 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 nurse is performing a neurologic assessment of a 7-month-old infant. What reflex should the nurse be able to elicit? Moro Babinski Tonic neck Palmar grasp

Babinski The Babinski reflex remains evident throughout the first 12 months of life. The Moro or startle reflex disappears by 4 months of age. The tonic-neck reflex disappears by 4 months of age. The palmar grasp reflex lessens at 3 months and is replaced by the voluntary pincer grasp by 8 months.

At 20 hours of age a newborn is found to have a bilirubin concentration of 13 mg/dL (274 mcmol/L). Which finding most likely contributed to this bilirubin level? Clubfoot Cephalhematoma Caput succedaneum Gestation of 41 weeks

Cephalhematoma Cephalhematoma, bleeding into the periosteum of the skull, leads to hyperbilirubinemia. A child with a clubfoot does not have an increased risk of hyperbilirubinemia. Caput succedaneum is edema of the presenting part. It does not involve any bleeding. The postmature infant can better handle the bilirubin than the preterm infant.

A parent brings a 2-month-old infant with Down syndrome to the pediatric clinic for a physical and administration of immunizations. Which clinical finding should prompt the nurse to perform further assessment? Flat occiput Small, low-set ears Circumoral cyanosis Protruding furrowed tongue

Circumoral cyanosis Circumoral cyanosis is not a specific characteristic of Down syndrome. It is a clinical finding associated with congenital heart disease, which these infants may have as a concurrent problem. A flat occiput and a broad nose with a depressed bridge (saddle nose) are features of children with Down syndrome. Small, misshapen, low-set ears are also a clinical manifestation of Down syndrome. Children with Down syndrome often keep their mouths open, with their tongues protruding; the surface of the tongue is often wrinkled.

An infant with a myelomeningocele is scheduled for surgery to close the defect. Which nursing action best facilitates the parent-child relationship in the preoperative period? Encouraging the parents to stroke their infant Allowing the parents to hold their infant in their arms Referring the parents to the Spina Bifida Association of America (Canada: Spina Bifida and Hydrocephalus Association of Canada) Teaching the parents to use special techniques when feeding the infant

Encouraging the parents to stroke their infant Because the infant cannot be held, tactile stimulation helps meet the infant's needs and fosters bonding with the parents. An infant with an unrepaired myelomeningocele cannot be held in the arms. Referrals will be more appropriate at a later time. Although special feeding techniques are important in the postoperative period, they may not improve the parent-infant relationship.

Neonates have difficulty maintaining their body temperature; however, their bodies have several mechanisms to help them do so. Which ones should a nurse remember when caring for the newborn? Flexed fetal position Hepatic insulin stores Brown fat metabolism Peripheral vasoconstriction Parasympathetic nervous system

Flexed fetal position brown fat metabolism peripheral vasoconstriction Full-term neonates maintain a flexed fetal position, which conserves heat. Deposition of brown fat begins at 28 weeks' gestation and continues for the rest of the pregnancy; when the newborn's body becomes cool, the sympathetic nervous system stimulates the breakdown of brown fat, which releases heat as a by-product. Peripheral vasoconstriction helps conserve heat by keeping the central core warm and preventing heat from dissipating. Insulin is not stored in the liver and is not involved with maintenance of neonatal body temperature. The sympathetic, not parasympathetic, nervous system is involved in thermoregulation.

What should the plan of care for a newborn with hypospadias include? Preparing the infant for insertion of a cystostomy tube Explaining to the parents the genetic basis for the defect Keeping the infant's penis wrapped with petrolatum gauze Giving the parents reasons why circumcision should not be performed

Giving the parents reasons why circumcision should not be performed. The parents need to know why circumcision should not be performed. The foreskin may be needed for repair and reconstruction of the penis. A cystostomy tube is not inserted, because there is no interference with voiding. Hypospadias is not a genetic disorder, although there appears to be some evidence that it is familial. The penis is generally wrapped in petrolatum gauze after, not before, surgical correction of hypospadias.

During a newborn assessment for developmental dysplasia of the hip (DDH), the nurse elicits the Ortolani sign. How does the nurse explain this finding to the child's mother? It is a broadening of the perineum. It is shortening of the affected leg. It is a clicking of the hip when it is manipulated. It is drooping of the hip on one side of the body.

It is a clicking of the hip when it is manipulated. With specific manipulation, an audible click may be heard or felt as the femoral head slips into the acetabulum. Broadening of the perineum is associated with bilateral dislocation. The apparent shortening of one leg is the Allis sign. A unilateral droop of one hip is the Trendelenburg sign; it occurs in a child with developmental dysplasia of the hip when the child bears weight.

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? Knee-chest Orthopneic Lateral Sims Semi-Fowler

Knee-chest 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.

A parent arrives in the emergency clinic with a 3-month-old baby and says, "My baby stopped breathing for a while!" The infant continues to have difficulty breathing, with prolonged periods of apnea. Which assessment data should prompt the nurse to suspect shaken baby syndrome (SBS)? Birth occurred before 32 weeks' gestation Lack of stridor and adventitious breath sounds Previous episodes of apnea lasting 10 to 15 seconds Retractions and use of accessory respiratory muscles

Lack of stridor and adventitious breath sounds One common sign of SBS is apnea without stridor or adventitious sounds, the result of central nervous system trauma. The age of the infant is beyond the time that respiratory distress caused by immaturity would occur. Short periods of apnea, lasting less than 15 seconds, are expected at any age. Retractions and use of accessory respiratory muscles are indicative of laryngotracheobronchitis, which is common in children younger than 5 years of age but would not be expected at 3 months.

A 4-month-old infant is brought to the emergency department after 2 days of diarrhea. The infant is listless and has sunken eyeballs, a depressed anterior fontanel, and poor tissue turgor. The infant's breathing is deep, rapid, and unlabored. The mother states that the infant has had liquid stools and no obvious urine output. What problem does the nurse conclude that the infant is experiencing? Kidney failure Mild dehydration Metabolic acidosis Respiratory alkalosis

Metabolic Acidosis Metabolic acidosis occurs with loss of alkaline fluid through diarrhea and is manifested by lethargy and Kussmaul breathing; all of the assessments indicate severe dehydration. The infant has not urinated because excessive amounts of fluid have been lost in the loose stools; this indicates that the kidneys are functioning by compensating for the fluid loss. All data indicate a severe, not mild, fluid volume deficiency. Respiratory alkalosis is caused by an excessive loss of carbon dioxide, not diarrhea.

An infant is admitted to the pediatric unit with the diagnosis of heart failure. What should the nurse include in the infant's plan of care? increase the infant's fluid intake. Position the infant flat on the back. Offer the infant small, frequent feedings. Measure the infant's head circumference

Offer the infant small, frequent feedings. Because infants with heart failure become extremely fatigued while suckling, small, frequent feedings with adequate rest periods between can improve their total intake. Infants with heart failure usually have fluids restricted to reduce the cardiac workload. Lying flat restricts lung expansion and should be avoided; positioning with the upper body elevated facilitates respirations. Infants with heart failure are not prone to hydrocephalus and do not need to have head circumference measured again if the initial newborn assessment findings are within expected limits.

The nurse is reevaluating a newborn who had an axillary temperature of 97° F (36.1° C) and was placed skin to skin with the mother. The newborn's axillary temperature is still 97° F (36.1° C) after 1 hour of skin-to-skin contact. Which intervention should the nurse implement next? Placing the newborn under a radiant warmer in the nursery Checking the newborn for a wet diaper and then continue the skin-to-skin contact Leaving the newborn in skin-to-skin contact and rechecking the temperature in 1 hour Double-wrapping the newborn in warm blankets and returning the newborn to a crib by the mother's bedside

Placing the newborn under a radiant warmer in the nursery The newborn's temperature should be kept in the normal range of 97.7° F to 99.5° F (36.5° C to 37.5° C). A hypothermic temperature that has not improved in 1 hour with the use of skin-to-skin contact requires additional measures. The infant should be placed under a radiant warmer for a short time until the temperature returns to the normal range. Continuing skin-to-skin contact would not resolve the problem of hypothermia. Double-wrapping the newborn in warm blankets and leaving the newborn at the bedside would not be an adequate means of resolving the hypothermia.

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? Use of disposable diapers Prolonged contact with an irritant Decreased pH of the infant's urine Too-early introduction of solid foods

Prolonged Contact with irritant 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 most important for the nurse to include in the plan of care to best meet the needs of a neglected 6-month-old infant? Arrange to have staff members pick up and play with the infant whenever possible. Design a program that provides activities geared to a 6-month-old's developmental level. Provide consistent caregivers who will provide stimulation that is moderate and purposeful. Schedule care that allows for stimulation and physical contact by a variety of staff members.

Provide consistent caregivers who will provide stimulation that is moderate and purposeful. A consistent caregiver enhances formation of a trusting and mutually satisfying relationship between infant and caregiver. Overstimulation should be avoided. The infant may be developmentally delayed; this may cause overstimulation. A consistent caregiver, rather than multiple caregivers, enhances the development of trust.

For what additional defect should the nurse assess an infant with exstrophy of the bladder?

Pubic bone malformation; The pubic bone and the bladder form during the same period of embryonic development

What procedure should a nurse use when elevating the head of an infant in a spica cast?

Raising the entire mattress at the head of the crib When elevation of the head is desired, the entire mattress or crib should be raised at the head of the crib. There is no reason to place such a short time limit on this position. Pillows under the head or shoulders of a child in a spica cast will thrust the chest forward against the cast, resulting in discomfort and respiratory distress. Padding the edge of the cast with folded diapers will not help elevate the infant's head.

The nurse is caring for a 12-month-old infant with a diagnosis of failure to thrive. The infant's weight is below the third percentile, and development is delayed. Which behaviors of the child suggest to the nurse the possibility of parental neglect? Stiff Withdrawn Easily satisfied Minimal smiling Responsive to touch Little interest in the environment

Stiff Withdrawn Minimal Smiling Little Interest in Environment Infants with failure to thrive resulting from parental neglect are either stiff and unyielding or flaccid and unresponsive. These infants have difficulty reaching out to the environment and tend to be withdrawn. They get little response from parents and do not learn how to respond to others. These infants show little satisfaction, are very difficult to comfort, and are nonresponsive or minimally responsive to human contact. These infants have social and language deficits and display minimal interest in the environment or others.