Infants NCO
The mother of an infant with hypertrophic pyloric stenosis (HPS) asks the nurse many questions about the problem. What information should the nurse convey when answering these questions? 1. Surgery is usually necessary. 2. Chromosomal mutation is the cause. 3. Slow feeding will be required for several months. 4. Dietary restrictions must be maintained throughout childhood.
1. surgery is usually necessary Rationale: Surgery is the treatment of choice for HPS. After surgery the infant usually has a rapid recovery with an excellent prognosis. HPS is not caused by a chromosomal mutation; it is a structural defect in which hypertrophy of the circular muscle of the pylorus causes obstruction at the pyloric sphincter. The infant will be tolerating regular feedings within 24 hours of surgery. A special diet is not required once fluids are tolerated.
When explaining the occurrence of febrile seizures to a parents' class, what information should the nurse include? 1. They may occur in minor illnesses. 2. The cause is usually readily identified. 3. They usually do not occur during the toddler years. 4. The frequency of occurrence is greater in females than males.
1. they may occur in minor illnesses Rationale: 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.
At the age of 3 weeks an infant undergoes surgery to repair a cleft lip. What should postoperative nursing care include? 1. Using a spoon to administer oral feedings 2. Cleansing the suture line to prevent infection 3. Offering a pacifier for sucking to prevent crying 4. Using wrist restraints to keep the infant's hands away from the face
2. cleansing the suture line to prevent infection Rationale: Meticulous care of the suture line is necessary to prevent infection and to help ensure the best cosmetic effect. Using a spoon is contraindicated, because it could disrupt the suture line; the infant may be fed with a device that is designed especially for this purpose. Offering a pacifier is contraindicated, because sucking will put tension on the suture line and may result in disruption of the sutures. Elbow restraints are used; this allows the infant to move the arms without bending the elbows and thus prevents the infant from touching the face.
A 3-month-old infant has been hospitalized with respiratory syncytial virus (RSV). What is the priority intervention? 1. Administering an antiviral agent 2. Clustering care to conserve energy 3. Offering oral fluids to promote hydration 4. Providing an antitussive agent whenever necessary
2. clustering care to conserve energy Rationale: Often the infant will have a decreased pulmonary reserve, and the clustering of care is essential to provide for periods of rest. Antiviral therapy is controversial for this age group and is not given unless complications ensue. Intravenous fluids are given during the acute phase to prevent dehydration. Antitussive agents are not used; nasal secretions are aspirated with the use of a bulb syringe whenever necessary.
The neonate has a protruding tongue and a crease that transverses the entire width of each palm. The nurse recognizes that these findings are characteristic of what congenital condition? 1. Hypothyroidism 2. Down syndrome 3. Turner syndrome 4. Fetal alcohol syndrome
2. down syndrome Rationale: Dysmorphic features that are characteristic of Down syndrome include a protruding tongue and simian creases across the palms. A protruding tongue but not the transverse palmar creases may also occur with hypothyroidism. Turner syndrome is characterized by a webbed neck and peripheral edema. Children with fetal alcohol syndrome have dysmorphic features, but these are different from the ones that occur with Down syndrome.
The mother of an infant with a congenital heart defect who was admitted to the pediatric unit with heart failure asks why her baby must be weighed each morning. The nurse explains that the baby's treatment is based on changes in the daily weight. What complication can be prevented if treatment is successful? 1. Renal failure 2. Fluid retention 3. Digitalis toxicity 4. Protein malnutrition
2. fluid retention Rationale: Fluid retention is reflected by an excessive weight gain in a short period of time; inadequate cardiac output decreases blood flow to the kidneys, which leads to increased intracellular fluid and hypervolemia. Daily weights are appropriate if renal disease or hypovolemia is present; however, other assessments such as hourly urine output, blood urea nitrogen, and creatinine values provide a more accurate assessment of kidney function. Weight is helpful in determining medication dosages, but daily weights are not used to diagnose digitalis toxicity. Weight gain or loss resulting from nutritional intake is gradual and will not vary on a day-to-day basis.
An infant is admitted to the pediatric unit with bronchiolitis caused by respiratory syncytial virus (RSV). What interventions are appropriate nursing care for the infant? Select all that apply. 1. Limiting fluid intake 2. Instilling saline nose drops 3. Maintaining contact precautions 4. Suctioning mucus with a bulb syringe 5. Administering warm humidified oxygen
2. instilling saline nose drops 3. maintaining contact precautions 4. suctioning mucus with a bulb syringe Rationale: Saline nose drops help clear the nasal passage, which improves breathing and aids the intake of fluids. RSV is contagious; infants with RSV should be isolated from other children, and the number of people visiting or caring for the infant should be limited. Infants with RSV produce copious amounts of mucus, which hinders breathing and feeding; suctioning before meals and at naptime and bedtime provides relief. Fluid intake should be increased; adequate hydration is essential to counter fluid loss. These infants have difficulty nursing and often vomit their feedings. If measures such as suctioning before feeding and instilling saline nose drops are ineffective, intravenous fluid replacement is instituted. The humidified oxygen should be cool. It relieves the dyspnea and hypoxia that is prevalent in infants with RSV.
An 8-month-old infant undergoes surgical correction for hypospadias. What is a priority nursing intervention during the postoperative period? 1. Ensuring that privacy is maintained 2. Minimizing pain with adequate analgesia 3. Restricting fluid intake until the stent is removed 4. Gradually increasing the time that the urinary catheter is clamped
2. minimizing pain with adequate analgesia Rationale: Although analgesia is important to minimize pain, it also relaxes the infant, who may be immobilized to maintain the position of the urethral stent and to ensure optimal healing of the newly formed urethra. Infants are accustomed to a lack of privacy because of the need to expose the perineum and touch the genitalia when cleaning the area. Fluid intake should be encouraged, not restricted. The indwelling catheter is not clamped; backup pressure could disturb the suture line.
A nurse is caring for a child with the diagnosis of lead poisoning. For which problem should the nurse assess the child initially? 1. Constipation resulting from the excretion of lead 2. Neurologic injury caused by the ingestion of lead 3. Delayed development resulting from parental neglect 4. Inadequate nutrition resulting from decreased iron intake
2. neurologic injury caused by the ingestion of lead Rationale: The most serious and irreversible effects of lead toxicity are in the nervous system; lead encephalopathy causes seizures, cognitive impairment, paralysis, blindness, and ultimately coma and death. Although constipation may occur, it is not caused by the excretion of lead; lead is excreted by way of the urinary tract. Although some studies have identified that some children with plumbism have received less-than-adequate care, a cause-and-effect relationship between plumbism and parental neglect has not been established. Inadequate nutrition is not caused by a decrease in the intake of iron; a high serum blood level of lead interferes with the biosynthesis of heme, preventing the formation of hemoglobin, which results in anemia.
A mother arrives in the emergency department with her severely dehydrated infant. After being treated aggressively, the infant is rehydrated and ready to be discharged. What is the priority concern that the nurse should include in the discharge teaching plan for the mother? 1. Importance of a well-balanced diet 2. Signs of dehydration in infants 3. The need for cleanliness of feeding utensils 4. Effect of antibiotics on viral gastroenteritis
2. signs of dehydration in infants Rationale: It is most important for the mother to learn that immediate treatment is necessary for an infant with vomiting or diarrhea. Because infants have a greater proportion of body fluid to tissue than adults, they cannot maintain fluid balance in the event of a large loss of fluid through vomiting or diarrhea. An infant's diet consists almost totally of milk; teaching the mother about a well-balanced diet is irrelevant at this time. Although cleanliness is important, diarrhea may occur despite cleanliness. Antibiotics are not administered for viral gastroenteritis.
A nurse is conducting a physical assessment of an infant with pyloric stenosis. What clinical findings does the nurse expect? Select all that apply. 1. Boardlike abdomen 2. Visible peristaltic waves 3. Decreased bowel sounds 4. Cramping movements in the lower abdomen 5. Olive-shaped mass in the right upper quadrant
2. visible peristaltic waves 5. olive-shaped mass in the right upper quadrant Rationale: Gastric peristaltic waves are visible because the stomach is attempting to propel its contents through the stenotic pyloric sphincter. The hypertrophied muscle becomes elongated and is palpable as an olive-shaped mass. Because of its anatomic location, it is felt in the upper right quadrant of the abdomen. The upper abdomen may be distended, not boardlike, because food is unable to leave the stomach and progress through the remainder of the gastrointestinal tract. Transmission of ingested food is interrupted, but digestive processes are intact; therefore bowel sounds are heard. Gastric peristaltic waves, not cramping movements in the lower abdomen, may be observed.
A nurse is caring for a 9-month-old infant with severe dehydration. What does the nurse expect to note while completing a physical assessment of this infant? 1. Frothy stools 2. Weak, rapid pulse 3. Pale, copious urine 4. Bulging anterior fontanel
2. weak, rapid pulse Rationale: A weak, rapid pulse is an expected adaptation with a state of severe dehydration because of hypovolemia. Children with untreated cystic fibrosis and celiac disease have frothy stools. There is no indication that this infant has either of these disorders. Severe dehydration results in decreased urine output and concentrated urine. One of the signs of dehydration in an infant is a sunken, not bulging, anterior fontanel.
After several episodes of intermittent abdominal pain and vomiting, a 5-month-old infant is admitted to the pediatric unit. A diagnosis of intussusception is made. What is the priority nursing assessment that will help confirm the diagnosis? 1. Auscultating for bowel sounds 2. Listening for high-pitched crying 3. Measuring fluid intake and output 4. Observing characteristics of stools
4. observing characteristics of stools Rationale: Intussusception is a type of intestinal obstruction in which the intestine telescopes and becomes trapped within its lumen; the resulting stools are red and currant jelly-like because of the mixture of stool with blood and mucus. Bowel sounds may not be significantly affected. High-pitched crying is a result of cerebral irritation; this is not expected with intussusception. Accurate fluid intake and output records are important, but they are not essential to confirming this diagnosis.
A nurse is caring for an infant after a cleft lip repair. Which item should the nurse use to feed the infant for several days after the surgery? 1. Preemie nipple 2. Nasogastric tube 3. Gravity-flow nipple 4. Rubber-tipped syringe
4. rubber tipped syringe Rationale: A rubber-tipped syringe minimizes sucking and is not irritating to the suture line. Using a preemie nipple is one method of feeding before surgery. A nasogastric tube is unnecessary; the infant is hungry enough to feed even if deprived of sucking. Using a gravity-flow nipple is one method of feeding before surgery.
The parents of a 6-month-old infant ask the nurse about the best toy to buy for their baby. What type of toy should the nurse suggest? 1. Push-pull 2. Wooden blocks 3. Shape-matching 4. Soft stuffed animals
4. soft stuffed animals Rationale: A stuffed animal is the most appropriate toy for a 6-month-old infant because it is safe and cuddly and requires only gross motor movement. A push-pull toy is appropriate for the older infant (9 to 12 months) or toddler because it encourages walking. Wooden blocks are inappropriate because an infant puts toys in the mouth; playing with blocks requires motor development beyond the ability of a 6-month-old infant. Shape-matching toys require intellectual and motor development beyond that of an infant.
The condition of a child dying of leukemia deteriorates, and the child becomes comatose. The parents state that a relative told them that they should not allow the child to be resuscitated, but they are unsure. Which response by the nurse best demonstrates recognition of the ethical issues involved? 1. "Let me tell you about the implications of a DNR order, and then you can decide." 2. "Maybe you should talk with your doctor first; I'll be happy to make the call for you." 3. "You should discuss this thoroughly with your doctor and with your religious adviser." 4. "The final decision must be made by you and your doctor, but it's important to talk about it."
4. the final decision must be made by you and your doctor, but it's important to talk about it. Rationale: Telling the parents that they and the healthcare provider must make the final call but that it's important to discuss the issue is an ethically sound response that clearly defines who is involved in the decision making and allows parental expression of ideas and thoughts. Discussion of the implication of a do-not-resuscitate order should not take place until after the family has spoken with the practitioner. Although telling the parents to discuss the issue with the healthcare provider and offering to make the call promotes the practitioner-client relationship, it stops nurse-client interaction. Telling the parents to discuss the issue with the healthcare provider and religious adviser abdicates nursing responsibility, and the parents may have no desire to involve a religious adviser in the decision making process.
A parent tells the nurse, "My 9-month-old doesn't have the same strong grasp that she had when she was born, and she's not startled by loud noises anymore." How should the nurse explain these changes in behavior? 1. "Let me check these responses before deciding how to proceed." 2. "When these responses fail, it may indicate a developmental delay." 3. "The baby needs more sensory stimulation to get these responses back." 4. "Those responses are replaced by voluntary activity around 5 months of age."
4. those responses are replaced by voluntary activity around 5 months of age Rationale: Touching the palm of a newborn causes flexion of the fingers (grasp reflex ); this response usually diminishes after 3 months of age. An unexpected loud noise causes the newborn to abduct the extremities and then flex the elbows (startle reflex); this response usually disappears by 4 months of age. Persistence of primitive reflexes is usually indicative of a developmental delay. It is not necessary to gather more data, because these changes are consistent with expected growth and development. The data do not support the conclusion that the child is developmentally delayed, and saying so may cause needless concern. Sensory stimulation at this age is directed toward experiences to add new motor, language, and social skills.
Which nursing intervention provides the most support to the parents of an infant with an obvious physical anomaly? 1. Encouraging them to express their concerns 2. Discouraging them from talking about their baby 3. Encouraging them not to worry because the anomaly can be repaired 4. Showing them postoperative photographs of infants who had a similar anomaly
1. encouraging them to express their concerns Rationale: Encouraging parents to express their concerns helps and encourages them to put their fears and feelings into words. Once these sentiments are expressed, they can then be examined and addressed. Discouraging the parents from talking about their baby will not help them cope with the problem, nor will it demonstrate the supportive, empathetic role of the nurse. Encouraging them not to worry because the anomaly can be repaired lacks insight, and parents will worry about their infant anyway. Showing postoperative photographs of infants who had a similar anomaly may or may not be helpful.
A nurse is selecting toys for a 5-month-old infant. Which toy should not be given to the infant? 1. Large snap beads 2. Soft stuffed animals 3. Rattles that can be held 4. Brightly colored mobiles
1. large snap beads Rationale: Fine motor coordination is developed inadequately for manipulation of snap toys. Soft stuffed animals stimulate the sense of touch, and because voluntary grasp appears at about 3 to 4 months, they can be handled satisfactorily. The voluntary grasp will allow the child to hold a rattle, and the rattling sound will stimulate the auditory system. Bright mobiles are appropriate to stimulate visual attention.
A nurse who is caring for a 2-day-old neonate suspects that the infant has cystic fibrosis. What early sign of this disorder did the nurse identify? 1. Meconium ileus 2. Imperforate anus 3. Hemoglobin level of 20 g/dL (200 mmol/L) 4. Total bilirubin level of 8 mg/dL (136 mcmol/L)
1. meconium ileus Rationale: The intestines of newborns with cystic fibrosis may be obstructed by thick, tenacious, pasty meconium. Imperforate anus, a congenital malformation in which the anal opening is obliterated, is identified during the newborn's initial assessment; it is not associated with cystic fibrosis. At birth fetal hemoglobin remains in the newborn's circulation for several weeks. The fetal hemoglobin level is high to compensate for the fetus's low oxygenation. A newborn's hemoglobin level is 14.5 to 22.5 g/dL (145 to 225 mmol/L). An increased bilirubin level, which commonly occurs in newborns because of the destruction of fetal erythrocytes, is called physiologic jaundice. This occurs more often in breastfed newborns than in formula-fed newborns.
A parent asks the nurse, "The doctor said my baby has something called pulmonic stenosis. What does that mean?" What is the best response by the nurse? 1. "What else did the doctor say?" 2. "Your baby has a heart problem." 3. "Are you concerned about the baby?" 4. "I'll page your doctor so you can discuss this again."
1. what else did the doctor say? Rationale: The nurse should know how much information the parent has before responding. Pulmonic stenosis, a narrowing of the pulmonic valve at the entrance to the pulmonary artery, may vary in severity. Treatment may vary from balloon angioplasty to valvotomy. The mother must know by this time that her infant has a heart problem; telling the mother this is too vague yet too blunt. The parent is obviously concerned, or she would not have asked the question. Referring the mother back to the healthcare provider is an abdication of the nurse's role.
What is the priority nursing action when a 3-month-old infant is receiving intravenous (IV) fluids by way of an antecubital vein? 1. Monitoring for infiltration behind the infant's elbow 2. Applying arm boards to prevent bending at the elbows 3. Checking both of the infant's pupils for dilation every hour 4. Telling the parents why they cannot hold the infant during IV therapy
2. applying arm boards to prevent bending at the elbows Rationale: The extremity should be placed in an arm board so the child will not bend the elbow and restrict the flow of IV fluids. First the flow of fluid must be ensured; then the nurse should inspect often for signs of infiltration at the IV insertion site, not the elbow. Pupil responses are unrelated to dehydration and fluid replacement. The parents can be taught how to hold their infant while an IV infusion is being administered
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 Rationale: 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.
A 5-month-old infant is brought to the pediatric clinic for a routine monthly examination. What assessment finding alerts the nurse to notify the healthcare provider? 1. Heart rate of 100 beats/min 2. Blood pressure of 75/48 mm Hg 3. Respiratory rate of 70 breaths/min 4. Temperature of 99.5° F (37.5° C)
3. respiratory rate of 70 breaths/min Rationale: The average respiratory rate for infants is 35 breaths/min. Tachypnea requires further investigation. A heart rate of 100 beats/min, blood pressure of 75/48 mm Hg, and temperature of 99.5° F (37.5° C) are all within the expected ranges for infants.
A newborn is found to have Down syndrome. The nurse knows that Down syndrome is usually accompanied by several problems. Which assessment should the nurse perform during the physical examination? 1. Reflex responses for hypotonicity 2. Eye examination for congenital cataracts 3. Sensory stimulation for muscle flaccidity 4. Cardiac irregularities for congenital heart disease
4. cardiac irregularities for congenital heart disease Rationale: Children with Down syndrome have a high incidence of congenital heart defects, indicated by altered heart sounds. Without treatment a heart defect may become life threatening. The other options are expected but are not life threatening.
A nurse is caring for an infant with a myelomeningocele. What does the nurse expect this infant to have that it is different from an infant with a meningocele? 1. Enlarged head 2. Sac over the lumbar area 3. Affected lower extremities 4. Infection of the spinal fluid
3. affected lower extremities Rationale: Failure of neural tube to close during the first 3 to 5 weeks of fetal development results in neural tube defects. Myelomeningocele is the most severe form; these children usually have lower extremity and bladder dysfunction. Hydrocephalus may occur after the repair of either a meningocele or a myelomeningocele. A saclike cyst containing meninges and spinal fluid may be present in either defect. Infection is possible with either defect because of the exposure of the meninges.
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 Rationale: 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.
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? 1. To prevent aspiration 2. To promote respiration 3. To reduce intracranial pressure 4. To maintain cleanliness of the suture site
3. to reduce intracranial pressure Rationale: 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.
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? 1. Shortly after birth 2. Between 4 and 5 years of age 3. Just before the onset of puberty 4. After 6 months and before 1 year of age
4. after 6 months and before 1 year of age Rationale: 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.
The nurse has taught newborn care and safety to a group of expectant mothers. Which statement by a mother indicates the need for additional teaching? 1. "I need to put my baby to bed on his back." 2. "I need to toddler-proof my house before the baby starts to walk." 3. "My baby could choke on any small object that will fit in her mouth." 4. "I'll keep my baby in a backward-facing car seat until he's a year old."
4. ill keep my baby in a backward-facing car seat until he's a year old Rationale: New guidelines recommend keeping a child in a backward-facing car seat until 2 years of age. Putting a baby to bed on his or her back will reduce the risk of sudden infant death syndrome. The house should be toddler-proofed when the child starts crawling. Choking is a major hazard for the young infant, who will place anything at hand in his or her mouth.