Infants
A parent of a healthy 8-month-old infant asks a nurse which pureed foods and type of milk are most appropriate at this age. What should the nurse suggest? 1 Applesauce, carrots, chicken, and formula 2 Pears, green beans, turkey, and whole milk 3 Bananas, sweet potatoes, ham, and formula 4 Peaches, cottage cheese, corn, and whole milk
1 Applesauce, carrots, chicken, and formula Applesauce, carrots, chicken, and formula are easily digested foods that should be introduced by 6 months of age; breast milk or formula, rather than cow's milk, is recommended for the first year of life. Ham is too high in fat and sodium for an infant younger than 1 year.
A 1-month-old infant with hydrocephalus is scheduled to have surgery for the insertion of a ventriculoperitoneal shunt. What is the primary focus of nursing interventions for this infant? 1 Maintaining a satisfactory comfort level to limit crying 2 Applying bandages to the infant's head to protect it from injury 3 Establishing a fixed feeding schedule to ensure appropriate hydration 4 Providing play objects to maintain age-appropriate stimulation for the child
1 Maintaining a satisfactory comfort level to limit crying Preventing crying will avoid sudden increases in intracranial pressure. Applying head bandages is inappropriate and unnecessary. Young infants, especially those with hydrocephalus, tolerate a demand schedule better, and it may diminish the possibility of vomiting. Providing toys is inappropriate for a 1-month-old infant.
A nurse in the pediatric clinic is assessing an 11-month-old client who is sitting on the mother's lap crying and tugging at the right ear. What likely problem does this behavior indicate? 1 Child abuse 2 Otitis media 3 Hearing impairment 4Upper respiratory infection
2 Otitis media Young children who cannot verbalize the presence of pain use nonverbal behaviors to indicate discomfort; crying and tugging at a painful ear are typical behaviors of an infant with otitis media. There are no data to indicate child abuse. Tugging at the ear is not an indication that the child has a hearing problem. Tugging at the ear is specific to otitis media, not an upper respiratory infection.
An infant is found to have hydrocephalus. Which assessment finding alerts the nurse to suspect increasing intracranial pressure? 1 Sunken eyes 2 Projectile vomiting 3 Depressed fontanels 4 Narrowing pulse pressure
2 Projectile vomiting Increased intracranial pressure exerts pressure on the vomiting center in the brain, resulting in projectile vomiting unrelated to feeding. The eyeballs will show signs of increased fluid volume in the skull and will be pushed forward, pulling the lids taut. The fontanels will show signs of increased fluid volume in the skull and therefore will bulge. With increased intracranial pressure the systolic pressure is increased and the diastolic pressure is the same or decreased, creating a widening, not narrowing, of pulse pressure.
An infant has exstrophy of the bladder. What does the nurse anticipate that the primary healthcare provider will prescribe to protect the exposed bladder area? 1 Antibacterial ointment 2 Pediatric urine collector 3 Warm, moist compresses 4 Sterile nonadherent dressings
4 Sterile nonadherent dressings
A new mother is concerned that her 1-month-old infant is nursing every 2 hours. Which response by the nurse is most appropriate? 1 "It's common for newborns to nurse this often. Let's talk about how you're adjusting with the new baby." 2 "Breast milk is easily digested; giving your infant a little rice cereal will keep him full longer." 3 "It sounds as though your baby is a little spoiled; try to resist feeding more often than every 4 hours." 4 "You may not be producing enough milk; it'll be important for you to supplement feedings with formula."
1 "It's common for newborns to nurse this often. Let's talk about how you're adjusting with the new baby." Newborns typically nurse every 2 to 3 hours. Although breast milk is easily digested, feeding solids to an infant is not recommended at this age. Feeding satisfies a fundamental need; one does not spoil an infant by nursing as needed. Adequate intake is evidenced in infant weight gain and adequate urinary and bowel elimination. Supplementing feedings with formula may lead to decreased milk production.
What is the best way for the nurse to promote the social development of a 9-month-old infant? 1 Engaging in peek-a-boo 2 Offering soft clay to manipulate 3 Providing a pegboard for pounding 4 Demonstrating how to speak words
1 Engaging in peek-a-boo Playing peek-a-boo is age appropriate because it aids the infant's social development by fostering a sense of object constancy and object permanence. Playing with soft clay is age appropriate for the toddler; it promotes gross and fine motor development. Pounding on a pegboard is age appropriate play for toddlers and preschoolers; it helps release tension and develops motor skills. Repeating words is age appropriate for the 1-year-old child.
An infant with bronchiolitis caused by respiratory syncytial virus (RSV) is admitted to the pediatric unit. What does the nurse expect the prescribed treatment to include? 1 Humidified cool air and adequate hydration 2 Postural drainage and oxygen by hood 3 Bronchodilators and cough suppressants 4 Corticosteroids and broad-spectrum antibiotics
1 Humidified cool air and adequate hydration Humidified cool air and hydration are essential to facilitating improvement in the child's physical status. Postural drainage is not effective with this disorder; oxygen is used only if the infant has severe dyspnea and hypoxia. Bronchodilators are not used, because the bronchial tree is not in spasm; cough suppressants are ineffective. Corticosteroids are ineffective; antibiotics are also ineffective, because the causative agent is viral.
A parent brings a 2-week-old infant to the clinic because the infant continually regurgitates. Chalasia, an incompetent cardiac sphincter, is suspected. What instructions should the nurse give the parent? 1 Keep the infant in an upright position after feedings. 2 Prevent the infant from crying for prolonged periods. 3 Keep the infant in the prone position after each feeding. 4 Ensure that the infant drinks a full bottle of formula at each feeding.
1 Keep the infant in an upright position after feedings.
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? 1 Start with small, frequent feedings. 2 Rock for 20 minutes after a feeding. 3 Keep the infant awake for 30 minutes after feeding. 4 Position the infant flat on the right side during feedings.
1 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 9-month-old infant who appears well nourished, alert, and happy is brought to the well-baby clinic for a routine physical examination. Using Erikson's theory of development, what task does the nurse determine that the infant is in the process of achieving? 1 Trust 2 Industry 3 Initiative 4 Autonomy
1 Trust Trust is developed if the infant's needs are being met by the caregivers. The task of industry should be successfully completed during the childhood years (6 to 12 years of age). The task of initiative should be successfully completed between 3 and 6 years of age. The stage of autonomy is successfully completed during the toddler years (1 to 3 years of age).
A nurse is feeding an infant who recently underwent surgical repair of a cleft lip. What does the nurse plan to do for the infant just after each feeding? 1 Burp several times. 2 Rinse the suture line. 3 Place on the abdomen. 4 Hold for several minutes.
2 Rinse the suture line. Meticulous care of the suture line is necessary, because inflammation and sloughing of tissue disrupt healing. Burping should be done throughout the feeding. Placing the infant on the abdomen is contraindicated, not only because the infant may rub the face on the sheet and irritate the suture line but also because this position has been linked to sudden infant death syndrome. The infant may be held at any time.
A 2-month-old infant is admitted to the pediatric unit with a diagnosis of respiratory syncytial virus infection. The nurse plans to position the infant to improve the respiratory effort. What positions are best? Select all that apply. 1 Prone 2 Semi-Fowler 3 Trendelenburg 4 Hyper-extended head 5 Head in sniffing position
2 Semi-Fowler 5 Head in sniffing position The semi-Fowler position allows gravity to pull the intestines away from the diaphragm, thereby improving respiration. When the infant's head is in a sniffing position the airway is shortened and respiratory function is improved. The prone position will not support respiratory function. The Trendelenburg position will put pressure on the diaphragm, restricting respirations. A hyperextended head restricts the airway.
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? 1 Flat occiput 2 Small, low-set ears 3 Circumoral cyanosis 4 Protruding furrowed tongue
3 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.
What is the nurse's priority intervention when preparing for admission of a child with acute laryngotracheobronchitis? 1 Padding the side rails of the crib 2 Arranging for a quiet, cool room 3 Placing a tracheostomy unit by the bedside 4 Obtaining a recliner so a parent can stay
3 Placing a tracheostomy unit by the bedside The priority is a patent airway; the equipment needed to ensure a patent airway must be immediately available. Although padding the rails of the crib is helpful, it is not the priority. Arranging for a quiet, cool room is unnecessary; it may be done if the child has a high fever or a history of febrile seizures. Although it is appropriate to obtain a recliner so a parent may stay, this is not the priority.
An infant with a myelomeningocele undergoes surgery and is returned to the pediatric unit. The father appears anxious and tends to avoid physical contact with the infant. Later he says to the nurse, "My wife seems so wrapped up with the baby; I hope she has time for me." What is the most therapeutic response by the nurse? 1 "Are you feeling that you'll have to fend for yourself?" 2 "Do you think maybe your parents will be able to help out?" 3 "You'll both be so busy, you won't even miss her attention." 4 "I can understand your concern about the changes you'll have to make."
4 "I can understand your concern about the changes you'll have to make." Validating the father's feelings lets the father know that the nurse understands that adjustments will have to be made. Also, it is open-ended enough to let him talk about feelings. Stating that the father is afraid that he will have to fend for himself is a premature assumption and is not open-ended enough to foster expression of feelings about what is bothering the father. The father has not expressed his feelings enough for the nurse to offer any specific suggestions for help. Saying that the father may be too busy may compound the father's anxiety; also, it does not let him explore feelings. Topics
A 3-month-old infant is admitted to the pediatric unit with a diagnosis of tetralogy of Fallot. The nurse's assessment reveals that the infant's weight has declined from the 25th percentile to the 5th. The nurse concludes that what is the most likely reason for this inadequate weight gain? 1 Cyanosis resulting in cerebral changes 2 Decreased arterial oxygen level resulting in polycythemia 3 Pulmonary hypertension resulting in recurrent respiratory infections 4 Inadequate oxygen perfusion leading to activity intolerance, resulting in diminished energy to nurse
4 Inadequate oxygen perfusion leading to activity intolerance, resulting in diminished energy to nurse Because of quick fatigue it is difficult for the infant to consume sufficient calories for adequate weight gain. Increased caloric intake is needed to meet the infant's nutritional needs. Although cyanosis is present, it may not lead to cerebral changes. Cyanosis is not directly related to inadequate weight gain. Although decreased Po2 does lead to polycythemia, it does not affect the infant's ability to gain adequate weight. Although there is pulmonary hypertension, it is not directly related to inadequate weight gain or respiratory infections.
A nurse is caring for an infant with heart failure. What treatment does the nurse most likely anticipate in the care of this infant? 1 Open heart surgery 2 Cardiac stress test 3 Aggressive intravenous fluid infusions 4 Medications that are prescribed for both children and adults
4 Medications that are prescribed for both children and adults Because the mechanism of heart failure is the same in children and adults, the same medications (e.g., cardiac glycosides, angiotensin-converting enzyme [ACE] inhibitors, and diuretics) are used, although the dosage will be adjusted for the infant and for the child. Open heart surgery may or may not be necessary; other treatments may be successful. A cardiac stress test is not an anticipated treatment for an infant. Also, a stress test is a diagnostic test, not a treatment. Aggressive fluid infusions are usually not ordered for clients in heart failure. Excessive fluid increases the workload of the heart.
A 7-month-old girl is to be catheterized so a sterile urine specimen may be obtained. One of the infant's parents expresses fear that this procedure may traumatize the baby psychologically. How should the nurse provide reassurance? 1 The fear is justified, and the nurse should obtain a "clean catch" specimen. 2 Parents have a right to refuse the catheterization, and the concerns are realistic. 3 Although the concern is appropriate, the need for a sterile specimen is the priority. 4 The procedure is uncomfortable, but there should not be a damaging long-term effect.
4 The procedure is uncomfortable, but there should not be a damaging long-term effect. The 7-month-old infant is accustomed to having the perineal area exposed and cared for and is not in a developmental stage in which fears related to sexuality are present. A "clean catch" at this age is often contaminated; therefore catheterization has been prescribed. The parents do have the right to refuse, but this concern is not realistic an infant of this age. The parent's concern is not appropriate for the developmental age of the infant.
