Infant
Which data collection finding would the nurse identify as abnormal for a 4-month-old infant? 1. The abdominal wall is rising with inspiration. 2. The respiratory rate is between 30and 35 breaths/minute. 3. The infant's skin is mottled during examination. 4. The spaces between the ribs (intercostal) are delineated during inspiration.
4. The spaces between the ribs (intercostal) are delineated during inspiration. RATIONALES: The presence of intercostal retractions is a sign of respiratory distress from an obstruction or a disease such as pneumonia, which causes the infant to have to work to breathe. Infants and children up to age 7 are abdominal breathers; after that age, they change to an adult pattern of breathing, which uses the diaphragmatic and thoracic muscles. A normal respiratory rate for an infant up to age 1 is 20 to 40 breaths/minute. An infant's skin can become mottled if the infant is left uncovered during the examination.
An infant who has been in foster care since birth requires a blood transfusion. Who's authorized to give written, informed consent for the procedure? 1. Foster mother who has been appointed legal guardian 2. Social worker who placed the infant in the foster home 3. Registered nurse caring for the infant 4. The nurse-manager on duty
1. Foster mother who has been appointed legal guardian RATIONALES: When children are minors and aren't emancipated, their parents or designated legal guardians are responsible for providing consent for medical procedures. Therefore, the foster mother is authorized to give consent for the blood transfusion because she has been appointed the legal guardian of the child. The social worker, the nurse, and the nurse-manager have no legal rights to give consent in this case.
The physician prescribes furosemide (Lasix), 2 mg/kg P.O., as a one-time dose for an infant with fluid overload. The infant's documented weight is 14 lb. The oral solution contains 10 mg/ml. How many milliliters of solution should the nurse administer?
1.3 ml RATIONALES: To perform the dosage calculation, first convert the infant's weight from pounds to kilograms by setting up the following proportion: 2.2 lb/1 kg = 14 lb/X X = 6.4 kg. Then perform the following calculation to determine the total dose prescribed: 2 mg/kg = X/6.4 kg X = 12.8 mg. Then set up the following proportion to determine the volume of medication to administer: 10 mg/ml = 12.8 mg/X X = 1.3 ml.
The nurse is caring for a neonate with congenital clubfoot. The child has a cast to correct the defect. Before discharge, what should the nurse tell the parents? 1. The cast will be removed in 6 weeks. 2. A new cast is needed every 1 to 2 weeks. 3. A short leg cast is applied when the baby is ready to walk. 4. The cast will be removed when the baby begins to crawl.
2. A new cast is needed every 1 to 2 weeks. RATIONALES: Because a neonate grows so quickly, the cast may need to be changed as often as every 1 to 2 weeks. A cast for congenital clubfoot isn't left on for 6 weeks because of the rapid rate of the infant's growth. By the time a baby is crawling or ready to walk, the final cast has long since been removed. After the cast is permanently removed, the baby may wear a Denis Browne splint until he's 1 year old.
A 10 month-old child with phenylketonuria (PKU) is being weaned from breast-feeding. When teaching the parents about the proper diet for their child, the nurse should stress the importance of restricting meats and dairy products because: 1. they're difficult for clients with PKU to digest. 2. they contain high levels of phenylalanine. 3. they aren't well tolerated in children with PKU until after age 2. 4. they lack phenylalanine, which stimulates muscle growth.
2. they contain high levels of phenylalanine. RATIONALE: PKU is an inherited disorder characterized by the inability to metabolize phenylalanine, an essential amino acid. Phenylalanine accumulation in the blood results in central nervous system damage and progressive mental retardation. However, early detection of PKU and dietary restriction of phenylalanine can prevent disease progression. Intake of high-protein foods, such as meats and dairy products, must be restricted throughout life because they contain large amounts of phenylalanine.
A mother and grandmother bring a 3-month-old infant to the well-baby clinic for a routine checkup. As the nurse weighs the infant, the grandmother asks, "Shouldn't the baby start eating solid food? My kids started on cereal when they were 2 weeks old." Which response by the nurse would be appropriate? 1. "The baby is gaining weight and doing well. There is no need for solid food yet." 2. "Things have changed a lot since your children were born." 3. "We've found that babies can't digest solid food properly until they're 4 months old." 4. "We've learned that introducing solid food early leads to eating disorders later in life."
3. "We've found that babies can't digest solid food properly until they're 4 months old." RATIONALES: Infants younger than 4 months lack the enzymes needed to digest complex carbohydrates. Option 1 doesn't address the grandmother's question directly. Option 2 is a cliché that may block further communication with the grandmother. Option 4 is incorrect because no evidence suggests that introducing solid food early causes eating disorders.
The nurse must administer a medication to an infant based on his weight in kilograms. The clients weight in pounds is 16. What is the client's weight in kilograms?
7.3 kg RATIONALES: Convert the infant's weight from pounds to kilograms by setting up this equation: X/16 lb = 1 kg/2.2 lb X = 7.3 kg.
