Module 11 High Risk Newborn and Pediatric

Which suggestion is appropriate to teach a mother who has a preschool child who refuses to take the medications for HIV infection? a. Mix medications with chocolate syrup or pudding b. Mix the medications with milk or an essential food. c. Skip the dose of medication if the child protests too much. d. Mix the medication in a syringe, hold the child down firmly, and administer the medication.

A Adding medication to a small amount of nonessential food the child finds tasty may be helpful in gaining the child's cooperation. Doses of medication should never be skipped. Fighting with the child or using force should be avoided. A nonessential food that will make the taste of the medication more palatable for the child should be the correct action. The administration of medications for the child with HIV becomes part of the family's everyday routine for years.

The nurse closely monitors the temperature of a child with nephrotic syndrome. The purpose of this is to detect an early sign of which possible complication? a. Infection b. Hypertension c. Encephalopathy d. Edema

A An exacerbation of the disease can occur after an infection. Temperature is not an indication of hypertension or edema. Encephalopathy is not a complication usually associated with nephrosis. The child will most likely have neurologic signs and symptoms. Edema does not manifest with an elevated temperature.

The nurse is planning care for an adolescent with AIDS. The priority nursing goal is to a. prevent infection. b. prevent secondary cancers. c. restore immunologic defenses. d. identify sources of infection.

A As a result of the immunocompromise that is associated with HIV infection, the prevention of infection is paramount. Preventing secondary cancers is not currently possible. Current drug therapy is affecting the disease progression; although not a cure, these drugs can suppress viral replication and prevent further deterioration. Case finding is not a priority nursing goal.

An infant with severe meconium aspiration syndrome (MAS) is not responding to conventional treatment. Which treatment may be necessary for this infant? a. Extracorporeal membrane oxygenation b. Respiratory support with ventilator c. Insertion of laryngoscope and suctioning of the trachea d. Insertion of an endotracheal tube

A Extracorporeal membrane oxygenation is a highly technical method that oxygenates the blood while bypassing the lungs, allowing the infant's lungs to rest and recover. The infant is most likely intubated and on a ventilator already. Laryngoscope insertion and tracheal suctioning are performed after birth before the infant takes the first breath.

The nurse is teaching the parents of a newborn who is going to receive phototherapy. What other measure does the nurse teach to help reduce the bilirubin? a. Increase the frequency of feedings. b. Increase oral intake of water between feedings. c. How to prepare the newborn for an exchange transfusion d. Wrap the infant in triple blankets to prevent cold stress during phototherapy.

A Frequent feedings prevent hypoglycemia, provide protein to maintain albumin levels in the blood and promote gastrointestinal motility and removal of bilirubin in the stools. More frequent breastfeeding should be encouraged. Avoid offering water between feedings, because the infant may decrease his or her milk intake. Breast milk or formula is more effective at removing bilirubin from the intestines. Exchange transfusions are seldom necessary but may be performed when phototherapy cannot reduce high bilirubin levels quickly enough. Wrapping the infant in blankets will prevent the phototherapy from getting to the skin and being effective. The infant should be uncovered and unclothed.

The nursing student learns how infants acquire immunity. Which statement about this process is correct? a. The infant acquires humoral and cell-mediated immunity in response to infections and immunizations. b. The infant acquires maternal antibodies that ensure immunity up to 12 months age. c. Active immunity is acquired from the mother and lasts 6 to 7 months. d. Passive immunity develops in response to immunizations.

A Infants acquire long-term active immunity from exposure to antigens and vaccines. Immunity is acquired actively and passively. The term infant's passive immunity is acquired from the mother and begins to dissipate during the first 6 to 8 months of life. Passive immunity is acquired from the mother. Active immunity develops in response to immunizations.

A nurse is teaching a class on acute kidney injury. The nurse relates that acute kidney injury as a result of hemolytic-uremic syndrome (HUS) is classified as a. Intrinsic renal. b. Prerenal. c. Postrenal. d. Chronic.

A Intrinsic renal acute renal failure is the result of damage to kidney tissue. Possible causes include HUS, glomerulonephritis, and pyelonephritis. Prerenal acute renal failure is the result of decreased perfusion to the kidney. Possible causes include dehydration, septic and hemorrhagic shock, and hypotension. Postrenal acute renal failure results from obstruction of urine outflow. Conditions causing postrenal failure include ureteropelvic obstruction, ureterovesical obstruction, or neurogenic bladder. Renal failure caused by HUS is of the acute nature. Chronic renal failure is an irreversible loss of kidney function, which occurs over months or years.

Which data should alert the nurse that the neonate is postmature? a. Cracked, peeling skin b. Short, chubby arms and legs c. Presence of vernix caseosa d. Presence of lanugo

A Loss of vernix caseosa, which protects the fetal skin in utero, may leave the skin macerated and appearing cracked and peeling. Postmature infants usually have long, thin arms and legs. Vernix caseosa decreases in the postmature infant. Absence of lanugo is common in postmature infants.

What is the primary nursing concern for a hospitalized child with HIV infection? a. Maintaining growth and development b. Eating foods that the family brings to the child c. Consideration of parental limitations and weaknesses d. Resting for 2 to 3 hours twice a day

A Maintaining growth and development is a major concern for the child with HIV infection. Frequent monitoring for failure to thrive, neurologic deterioration, or developmental delay is important for HIV-infected infants and children. Nutrition, which contributes to a child's growth, is a nursing concern; however, it is not necessary for family members to bring food to the child. Although an assessment of parental strengths and weaknesses is important, it will be imperative for health care providers to focus on the parental strengths, not weaknesses. This is not as important as the frequent assessment of the child's growth and development. Rest is a nursing concern, but it is not as high a priority as maintaining growth and development. Rest periods twice a day for 2 to 3 hours may or may not be appropriate.

What is the most common mode of transmission of human immunodeficiency virus (HIV) in the pediatric population? a. Perinatal transmission b. Sexual abuse c. Blood transfusions d. Poor handwashing

A Perinatal transmission accounts for the highest percentage (91%) of HIV infections in children. Infected women can transmit the virus to their infants across the placenta during pregnancy, at delivery, and through breastfeeding. Cases of HIV infection from sexual abuse have been reported; however, perinatal transmission accounts for most pediatric HIV infections. Although in the past some children became infected with HIV through blood transfusions, improved laboratory screening has significantly reduced the probability of contracting HIV from blood products. Poor handwashing is not an etiology of HIV infection.

Nursing care of the infant with neonatal abstinence syndrome should include a. Positioning the infant's crib in a quiet corner of the nursery b. Feeding the infant on a 2-hour schedule c. Placing stuffed animals and mobiles in the crib to provide visual stimulation d. Spending extra time holding and rocking the infant

A Placing the crib in a quiet corner helps avoid excessive stimulation of the infant. These infants have an increase calorie needs but poor suck and swallow coordination. Feeding should occur to meet these needs. Stimulation should be kept to a minimum.

What should the nurse include in a teaching plan for the parents of a child with vesicoureteral reflux? a. The importance of taking prophylactic antibiotics if prescribed b. Suggestions for how to maintain fluid restrictions c. The use of bubble baths as an incentive to increase bath time d. The need for the child to hold urine for 6 to 8 hours

A Prophylactic antibiotics are sometimes used to prevent urinary infection in a child with vesicoureteral reflux, especially if they are waiting for the results of imaging studies or have recurrent UTIs. If prescribed, the parents should be taught that the child must finish the entire course of antibiotics to prevent bacterial resistance. Fluids are not restricted when a child has vesicoureteral reflux. In fact, fluid intake should be increased as a measure to prevent UTIs. Bubble baths should be avoided to prevent urethral irritation and possible UTI. To prevent UTIs, the child should be taught to void frequently and never resist the urge to urinate.

Which dietary modification is appropriate for a child with chronic renal failure? a. Decreased protein b. Decreased fat c. Increased potassium d. Increased phosphorus

A Protein intake is restricted or strictly regulated because of the kidney's inability to remove waste products. A low-fat diet is not relevant to chronic renal failure. Potassium intake may be restricted because of the kidney's inability to remove it. Phosphorus is restricted to help prevent bone disease.

The nurse is caring for a neonate undergoing phototherapy. What action does the nurse include on the infant's care plan? a. Keep the infant's eyes covered under the light. b. Keep the infant supine at all times. c. Restrict parenteral and oral fluids. d. Dress the infant in only a T-shirt and diaper.

A Retinal damage from phototherapy should be prevented by using eye shields on the infant under the light. To ensure total skin exposure, the infant's position is changed frequently. Special attention to increasing fluid intake ensures that the infant is well hydrated. To ensure total skin exposure, the infant is not dressed.

A nurse in a well-child clinic is teaching parents about their child's immune system. Which statement by the nurse is correct? a. The immune system distinguishes and actively protects the body's own cells from foreign substances. b. The immune system is fully developed by 1 year of age. c. The immune system protects the child against communicable diseases in the first 6 years of life. d. The immune system responds to an offending agent by producing antigens.

A The immune system responds to foreign substances, or antigens, by producing antibodies and storing information. Intact skin, mucous membranes, and processes such as coughing, sneezing, and tearing help maintain internal homeostasis. Children up to age 6 or 7 years have limited antibodies against common bacteria. The immunoglobulins reach adult levels at different ages. Immunization is the basis from which the immune system activates protection against some communicable diseases. Antibodies are produced by the immune system against invading agents, or antigens.

The nurse observes a rash on a teen's face which is characteristic of systemic lupus erythematosus (SLE). What action by the nurse is most appropriate? a. Teach the teen about using sunscreen. b. Prepare the teen for a bone marrow biopsy. c. Educate the teen on proper use of antibiotics. d. Demonstrate how to use an Epi-pen.

A The nurse needs to provide education on managing the disease; one facet includes minimizing sun exposure so the nurse teaches the teen about the correct use of sunscreen. The teen will not have a bone marrow biopsy, need antibiotics, or have to use an Epi-pen.

A nurse is working in an allergy clinic and has performed skin testing on an adolescent. Seventeen minutes after the procedure, the nurse note the presence of a wheal at one of the sites. What conclusion does the nurse make about this response? a. The child is allergic to that substance. b. This result is indeterminate. c. The testing should be redone in another location. d. Anaphylaxis is imminent.

A The presence of a wheal within 30 minutes of skin testing is indicative of an allergy to the substance used. The test does not need to be repeated, and anaphylaxis is not imminent.

The mother of a child who was recently diagnosed with acute glomerulonephritis asks the nurse why the physician keeps talking about "casts" in the urine. The nurse explains that casts in the urine indicate a. glomerular injury. b. glomerular healing. c. recent streptococcal infection. d. excessive amounts of protein in the urine.

A The presence of red blood cell casts in the urine indicates glomerular injury. Casts in the urine are abnormal findings and are indicative of glomerular injury, not glomerular healing. A urinalysis positive for casts does not confirm a recent streptococcal infection. Casts in the urine are unrelated to proteinuria.

The primary clinical manifestations of acute kidney injury are which of the following? a. Oliguria and hypertension b. Hematuria and pallor c. Proteinuria and muscle cramps d. Bacteriuria and facial edema

A The principal feature of acute kidney injury is oliguria, and many children are hypertensive. Hematuria, pallor, proteinuria, cramps, bacteriuria, and edema are not principal features.

A newborn has meconium aspiration at birth. The nurse notes increasing respiratory distress. What action takes priority? a. Obtain an oxygen saturation. b. Notify the provider at once. c. Stimulate the baby to increase respirations. d. Prepare to initiate ECMO.

A This baby has a risk for, and signs of, persistent pulmonary hypertension. The nurse first checks an oxygen saturation then notifies the provider, or alternatively, gets the reading (and other assessments) while another nurse does the notification. This baby most likely has tachypnea so stimulation to increase respirations is not needed. ECMO may or may not be needed depending on whether or not other treatments work.

A nurse is caring for a preterm baby who weighs 4.8 pounds. What assessment finding indicates the baby is dehydrated? a. Urine output of 3.3 mL/hour b. Urine specific gravity of 1.001 c. Low serum sodium d. Weight gain of 43 g in one day

A This baby weighs 2.18 kg. Dehydration is noted with a urine output of <2 mL/kg/hour. A urine output of 3.3 mL is 1.5 mL/kg/hour and so indicates dehydration. The dilute urine specific gravity indicates overhydration as does the low serum sodium. The weight gain is normal (15 to 20 g/kg/day).

What action by the nurse is the most important action in preventing neonatal infection? a. Good hand hygiene b. Isolation of infected infants c. Separate gown technique d. Standard Precautions

A Virtually all controlled clinical trials have demonstrated that effective handwashing is responsible for the prevention of nosocomial infection in nursery units. The other actions do reduce risk but not nearly to the degree that good hand hygiene does.

A nurse is caring for a late preterm infant. What action by the nurse is inconsistent with best practice to prevent cold stress? a. Wean the infant directly to an open crib. b. Check temperature every 3 to 4 hours. c. Encourage kangaroo care. d. Place infant on a radiant warmer.

A Weaning to an open crib takes many steps and is not done directly because of the risk of cold stress. The other actions help prevent cold stress.

While caring for the postterm infant, the nurse recognizes that the fetus may have passed meconium prior to birth as a result of a. hypoxia in utero. b. NEC. c. placental insufficiency. d. rapid use of glycogen stores.

A When labor begins, poor oxygen reserves may cause fetal compromise. The fetus may pass meconium as a result of hypoxia before or during labor, increasing the risk of meconium aspiration. Meconium is not passed as a result of NEC, placental insufficiency, or rapid use of glycogen stores.

A woman who has had no prenatal care enters the labor and delivery unit in advanced labor. She has chickenpox. What action by the nurse is best? a. Place the woman in isolation. b. Give the woman immune globulin before delivery. c. Treat the woman with acyclovir. d. Administer antibiotics to the infant after birth.

A Women with varicella infections (chickenpox or shingles) need to be in isolation (airborne and contact per the CDC). There might not be enough time to administer immune globulin to the mother before delivery, but it could be given to the baby. Acyclovir is the drug of choice for treatment, but the staff needs to be protected from this infection through isolation precautions. Antibiotics are not used for this disease.

The mother of an HIV-positive infant who is 2 months old questions the nurse about which childhood immunizations her child will be able to receive. Which immunizations should an HIV-positive child be able to receive? (Select all that apply.) a. Hepatitis B b. DTaP c. MMR d. IPV e. HIB

ABDE Routine immunizations are appropriate. The MMR vaccination is not given at 2 months of age. If it were indicated, CD4+ counts are monitored when deciding whether to provide live virus vaccines. If the child is severely immunocompromised, the MMR vaccine is not given. The varicella vaccine can be considered on the basis of the child's CD4+ counts. Only IPV should be used for HIV-infected children.

The nurse tells the nursing student that late preterm infants are at increased risk for which of the following problems? (Select all that apply.) a. Problems with thermoregulation b. Cardiac distress c. Hyperbilirubinemia d. Sepsis e. Hyperglycemia

ACD Problems with thermoregulation, hyperbilirubinemia, and sepsis are common with late preterm infants. They typically have respiratory distress and hypoglycemia.

Which home care instructions should the nurse provide to the parents of a child with acquired immunodeficiency syndrome (AIDS)? (Select all that apply.) a. Give supplemental vitamins as prescribed. b. Yearly influenza vaccination should be avoided. c. Administer any antibiotics as prescribed. d. Notify the provider if the child develops a cough or congestion. e. Missed doses of antiretroviral medication should just be skipped.

ACD The parents are taught that vitamins are important, to have the child take all antibiotics (if prescribed) as ordered, and to notify the provider of coughs or congestion. The child should have yearly influenza vaccination, and if missed medication doses are noticed close to their scheduled time, they should be taken.

To maintain optimal thermoregulation for the premature infant, what action by the nurse is most appropriate? a. Bathe the infant once a day. b. Put an undershirt on the infant in the incubator. c. Assess the infant's hydration status. d. Lightly clothe the infant under the radiant warmer.

B Air currents around an unclothed infant will result in heat loss. Bathing causes evaporative heat loss. Assessing hydration will not maintain thermoregulation. Clothing is not worn when the infant is under a radiant warmer.

A young child with HIV is receiving several antiretroviral drugs. What is the purpose of these drugs? a. Cure the disease. b. Delay disease progression. c. Prevent the spread of disease. d. Treat Pneumocystis jiroveci pneumonia.

B Although not a cure, these antiviral drugs can suppress viral replication, preventing further deterioration of the immune system, and delay disease progression. At this time, cure is not possible. These drugs do not prevent the spread of the disease. Pneumocystis jiroveci prophylaxis is accomplished with antibiotics.

Which preterm infant should receive gavage feedings instead of a bottle? a. Sometimes gags when a feeding tube is inserted b. Is unable to coordinate sucking and swallowing c. Sucks on a pacifier during gavage feedings d. Has an axillary temperature of 98.4° F, an apical pulse of 149 beats/min, and respirations of 54 breaths/min

B An infant who cannot coordinate sucking, swallowing, and breathing should receive gavage feedings. The other infants are ready for bottle feedings.

Which statement by a school-age girl indicates the need for further teaching about the prevention of urinary tract infections (UTIs)? a. "I always wear cotton underwear." b. "I really enjoy taking a bubble bath." c. "I go to the bathroom every 3 to 4 hours." d. "I drink four to six glasses of fluid every day."

B Bubble baths should be avoided because they tend to cause urethral irritation, which leads to UTI. It is desirable to wear cotton rather than nylon underwear. Nylon tends to hold in moisture and promote bacterial growth, whereas cotton absorbs moisture. Children should be encouraged to urinate at least four times a day. An adequate fluid intake prevents the buildup of bacteria in the bladder.

The goal of treatment of the infant with phenylketonuria (PKU) is to a. cure cognitive delays. b. prevent central nervous system (CNS) damage. c. prevent gastrointestinal symptoms. d. prevent the renal system damage.

B CNS damage can occur as a result of toxic levels of phenylalanine. No cure exists for cognitive delays should they occur. Digestive problems are a clinical manifestation of PKU, but it is more important to prevent the CNS damage. PKU does not involve renal dysfunction.

You are the nurse caring for a 4-year-old child who has developed acute renal failure as a result of hemolytic-uremic syndrome (HUS). Which bacterial infection was most likely the cause of HUS? a. Pseudomonas aeruginosa b. Escherichia coli c. Streptococcus pneumoniae d. Staphylococcus aureus

B Children with HUS become infected by Escherichia coli, which is usually contracted from eating improperly cooked meat or contaminated dairy products. Pseudomonas aeruginosa, Streptococcus pneumoniae, and Staphylococcus aureus are not associated with HUS.

What is an appropriate intervention for a child with nephrotic syndrome who is edematous? a. Teach the child to minimize body movements. b. Change the child's position every 2 hours. c. Avoid the use of skin lotions. d. Bathe every other day.

B Frequent position changes decrease pressure on body parts and help relieve edema in dependent areas. The child with edema is at risk for impaired skin integrity. It is important for the child to change position frequently to prevent skin breakdown. Good skin hygiene consists of daily baths to remove irritating body secretions and applying lotion.

The nurse learns that the most common cause of pathologic hyperbilirubinemia is which of the following? a. Hepatic disease b. Hemolytic disorders in the newborn c. Postmaturity d. Congenital heart defect

B Hemolytic disorders in the newborn are the most common cause of pathologic jaundice. Hepatic damage and prematurity may be causes of pathologic hyperbilirubinemia, but they are not the most common cause. Congenital heart defect is not a common cause of pathologic hyperbilirubinemia in neonates.

An infant with hypocalcemia is receiving an intravenous bolus of calcium. The infant's heart rate changes from 144 beats/minute to 62 beats/minute. What action by the nurse is best? a. Call for a stat EGG. b. Stop the infusion. c. Stimulate the infant. d. Administer magnesium.

B IV calcium can lead to bradycardia. When this infant's heart rate drops to 60 beats/minute, the nurse stops the infusion. A stat ECG is not necessary unless policy requires it or the bradycardia does not resolve. Stimulating the infant will not increase the heart rate. Magnesium infusion will also not increase the heart rate.

What is the primary nursing concern for a child having an anaphylactic reaction? a. Identifying the offending allergen b. Ineffective breathing pattern c. Increased cardiac output d. Positioning to facilitate comfort

B Laryngospasms resulting in ineffective breathing patterns is a life-threatening manifestation of anaphylaxis. The primary action is to assess airway patency, respiratory rate and effort, level of consciousness, oxygen saturation, and urine output. Determining the cause of an anaphylactic reaction is important to implement the appropriate treatment, but the primary concern is the airway. During anaphylaxis, the cardiac output is decreased. Positioning for comfort is not a primary concern during a crisis.

The difference between physiologic and nonphysiologic jaundice is that nonphysiologic jaundice a. usually results in kernicterus. b. appears during the first 24 hours of life. c. results from breakdown of excessive erythrocytes not needed after birth. d. begins on the head and progresses down the body.

B Nonphysiologic jaundice appears during the first 24 hours of life, whereas physiologic jaundice appears after the first 24 hours of life. Pathologic jaundice may lead to kernicterus, but it needs to be stopped before that occurs. Both jaundices are the result of the breakdown of erythrocytes. Pathologic jaundice is due to a pathologic condition, such as Rh incompatibility.

Parents of a newborn with phenylketonuria are anxious to learn about the appropriate treatment for their infant. What topic does the nurse include in the teaching plan? a. Fluid and sodium restrictions b. A phenylalanine-free diet c. Progressive mobility and splinting d. A protein-rich diet

B Phenylketonuria is treated with a special diet that restricts phenylalanine intake. Fluid and sodium restrictions are not included in this plan. Mobility and splinting are not included in the plan. A protein-rich diet is not in the plan.

The narrowing of preputial opening of foreskin is called a. chordee. b. phimosis. c. epispadias. d. hypospadias.

B Phimosis is the narrowing or stenosis of the preputial opening of the foreskin. Chordee is the ventral curvature of the penis. Epispadias is the meatal opening on the dorsal surface of the penis. Hypospadias is a congenital condition in which the urethral opening is located anywhere along the ventral surface of the penis.

What is most helpful in preventing premature birth? a. High socioeconomic status b. Adequate prenatal care c. Transitional Assistance to Needy Families d. Women, Infants, and Children nutritional program

B Prenatal care is vital in identifying possible problems. Women from higher economic status are more likely to seek adequate prenatal care, but it is the care that is most helpful. Government programs help with specific needs of the pregnant woman, but adequate care is more important.

In caring for the preterm infant, what complication is thought to be a result of high arterial blood oxygen level? a. Necrotizing enterocolitis (NEC) b. Retinopathy of prematurity (ROP) c. Bronchopulmonary dysplasia (BPD) d. Intraventricular hemorrhage (IVH)

B ROP is thought to occur as a result of high levels of oxygen in the blood. NEC is due to the interference of blood supply to the intestinal mucosa. Necrotic lesions occur at that site. BPD is caused by the use of positive pressure ventilation against the immature lung tissue. IVH is due to rupture of the fragile blood vessels in the ventricles of the brain. It is most often associated with hypoxic injury, increased blood pressure, and fluctuating cerebral blood flow.

Which is the Centers for Disease Control and Prevention (CDC, 2009) recommendation for immunizing infants who are HIV positive? a. Follow the routine immunization schedule. b. Routine immunizations are administered; assess CD4+ counts before administering the MMR and varicella vaccinations. c. Do not give immunizations because of the infant's altered immune status. d. Eliminate the pertussis vaccination because of the risk of convulsions.

B Routine immunizations are appropriate. CD4+ cells are monitored when deciding whether to provide live virus vaccines. If the child is severely immunocompromised, the MMR vaccine is not given. The varicella vaccine can be considered on the basis of the child's CD4+ counts. Only inactivated polio virus (IPV) should be used for HIV-infected children. The pertussis vaccination is not eliminated for an infant who is HIV positive.

Which finding indicates that a child receiving prednisone for primary nephrotic syndrome is in remission? a. Urine is negative for casts for 5 days. b. Urine has <1+ protein for 3 to 7 consecutive days. c. Urine is positive for glucose for 1 week. d. Urine is up to a trace for blood for 1 week.

B The child receiving steroids for the treatment of primary nephrotic syndrome is considered in remission when the urine has <1+ protein for 3 to 7 consecutive days. The absence of casts, presence of glucose, and presence of hematuria do not constitute remission.

Parents ask the nurse, "When should our child's hypospadias be corrected?" The nurse responds that correction of hypospadias should be accomplished by the time the child is a. 1 month of age. b. 6 to 12 months of age. c. school age. d. sexually mature.

B The correction of hypospadias should ideally be accomplished by the time the child is 6 to 12 months of age and before toilet training. One month of age is too young for this procedure. It is preferable for hypospadias to be surgically corrected before the child enters school so that the child has normal toileting behaviors in the presence of his peers. Corrective surgery for hypospadias is done long before sexual maturity.

Which factor predisposes the urinary tract to infection? a. Increased fluid intake b. Short urethra in young girls c. Prostatic secretions in males d. Frequent emptying of the bladder

B The short urethra in females provides a ready pathway for invasions of organisms. Increased fluid intake offers protective measures against UTIs. Prostatic secretions have antibacterial properties that inhibit bacteria. Frequent emptying of the bladder also offers protection against UTIs.

A nurse is caring for a preterm infant who has a weak cry and is irritable. What action by the nurse is best? a. Assess the infant for pain. b. Take the infant's temperature. c. Obtain a bedside glucose reading. d. Reduce stimulation in the environment.

B These are signs of inadequate thermoregulation. The nurse should assess the infant's temperature first. The other actions do not address thermoregulation.

A neonate has white patches in her mouth that bled when the mother tried wiping them away. What action by the nurse is best? a. Tell the mother to leave the patches alone. b. Assess the mother for a perineal rash. c. Give the infant medicated pacifiers. d. Test the infant for toxoplasmosis.

B These patches are characteristic of maternal infection with candidiasis or yeast. The nurse assesses the mother's perineal area for a rash. Telling the mother to leave the rash alone may be appropriate information but does not get to the bottom of the issue. The nurse should not provide medication without knowing what is being treated. The baby does not have toxoplasmosis.

A premature infant never seems to sleep longer than an hour at a time. Each time a light is turned on, an incubator closes, or people talk near her crib, she wakes up and cries inconsolably until held. The correct nursing diagnosis is ineffective coping related to a. severe immaturity. b. environmental stress. c. physiologic distress. d. behavioral responses.

B This nursing diagnosis is the most appropriate for this infant. Light and sound are known adverse stimuli that add to an already stressed premature infant. The nurse must monitor the environment closely for sources of overstimulation. The other diagnoses do not recognize that fact.

A child is admitted with acute glomerulonephritis. The nurse expects the urinalysis during this acute phase to show which of the following? a. Bacteriuria and hematuria b. Hematuria and proteinuria c. Bacteriuria and increased specific gravity d. Proteinuria and decreased specific gravity

B Urinalysis during the acute phase characteristically shows hematuria and proteinuria. Bacteriuria and changes is specific gravity would not be expected.

A woman who has a history of frequent substance abuse is close to delivering. What action by the nurse is best? a. Notify social services of the situation prior to the birth. b. Draw up and label a syringe of naloxone. c. Administer naloxone if the baby shows signs of withdrawal. d. Prepare to administer naloxone to the mother.

B When anticipating the delivery of a baby whose mother is addicted to opioids, the nurse prepares to give the newborn naloxone for respiratory depression. To administer the drug in the fastest way possible, the nurse prepares a syringe with the medication. Then when the baby's weight is known, the nurse discards the excess drug and administers the correct dose to the baby. Social services will need to be involved but not at this point; the medication is the priority. The naloxone may cause signs of withdrawal in the infant. The baby gets the naloxone, not the mother.

Newborns whose mothers are substance abusers frequently have what behaviors? (Select all that apply.) a. Circumoral cyanosis b. Decreased amounts of sleep c. Hyperactive Moro (startle) reflex d. Difficulty feeding e. Weak cry

BCD The infant exposed to drugs in utero often has poor sleeping patterns, hyperactive reflexes, and uncoordinated sucking and swallowing behavior. They do not have circumoral cyanosis and will have a high-pitched cry.

Some infants develop hypoxic-ischemic encephalopathy after asphyxia. Therapeutic hypothermia has been used to improve neurologic outcomes for these infants. Criteria for the use of this modality include (Select all that apply.) a. The infant must be 28 weeks gestation or greater. b. Have evidence of an acute hypoxic event. c. Be in a facility they can initiate treatment within 6 hours. d. The infant must be 36 or more weeks' gestation. e. The treatment must be initiated within the first 12 hours of life.

BCD The infant must be at least 36 weeks of gestation to meet the criteria for therapeutic hypothermia. Treatment should be initiated within the first 6 hours of life, ideally at a tertiary care center. The infant must have evidence of perinatal hypoxic-ischemic episodes.

An important nursing factor during the care of the infant in the NICU is assessment for signs of adequate parental attachment. The nurse must observe for signs that bonding is not occurring as expected. These include (Select all that apply.) a. using positive terms to describe the infant. b. showing interest in other infants equal to that of their own. c. naming the infant. d. decreasing the number and length of visits. e. refusing offers to hold and care for the infant.

BDE Bonding is not progressing as expected when parents show interest in other babies equal to that of their own, decreasing the number and length of visits, and refusing to hold and help care for the infant. Using positive terms to describe the baby and naming the infant are signs that bonding is occurring.

The nurse present at the delivery is reporting to the nurse who will be caring for the neonate after birth. What information might be included for an infant who had thick meconium in the amniotic fluid? a. The infant had Apgar scores of 6 and 8. b. An IV was started immediately after birth to treat dehydration. c. No meconium was found below the vocal cords when they were examined. d. The parents spent an hour bonding with the baby after birth.

C A laryngoscope is inserted to examine the vocal cords. If no meconium is below the cords, probably no meconium is present in the lower air passages, and the infant will not develop meconium aspiration syndrome. Apgar scores are important but not directly related to meconium. There is no relationship between dehydration and meconium fluid. Bonding is an expected occurrence.

What disorder is caused by a virus that primarily infects a specific subset of T lymphocytes, the CD4+ T cells? a. Raynaud phenomenon b. Idiopathic thrombocytopenic purpura c. Acquired immunodeficiency syndrome (AIDS) d. Severe combined immunodeficiency disease

C Acquired immunodeficiency is caused by the human immunodeficiency virus (HIV), which primarily attacks the CD4+ T cells. The other disorders are not viral in nature.

The nurse assessing a child with acute poststreptococcal glomerulonephritis should be alert for which finding? a. Increased urine output b. Hypotension c. Tea-colored urine d. Weight gain

C Acute poststreptococcal glomerulonephritis is characterized by hematuria, proteinuria, edema, and renal insufficiency. Tea-colored urine is an indication of hematuria. In acute poststreptococcal glomerulonephritis the urine output may be decreased. In acute poststreptococcal glomerulonephritis blood pressure may be increased. Edema may be noted around the eyelids and ankles in patients with acute post streptococcal glomerulonephritis and can contribute to weight gain; however, weight gain is associated more with nephrotic syndrome.

Transient tachypnea of the newborn (TTN) is thought to occur as a result of a. a lack of surfactant. b. hypoinflation of the lungs. c. delayed absorption of fetal lung fluid. d. a slow vaginal delivery associated with meconium-stained fluid.

C Delayed absorption of fetal lung fluid is thought to be the reason for TTN. Lack of surfactant and hypoinflation of the lungs are not related to TTN. A slow vaginal delivery will help prevent TTN.

A 5-year-old child has acquired immunodeficiency syndrome (AIDS). What statement by the mother indicates good understanding of medications used for this condition? a. "When my child's pain increases, I double the recommended dosage of antiretroviral medication." b. "Addiction is a risk, so I only use the medication as ordered." c. "Doses of the antiretroviral medication are selected on the basis of my child's age and growth." d. "By the time my child is an adolescent she will not need her antiretroviral medications any longer."

C Doses of antiretroviral medication to treat HIV infection for infants and children are based on individualized age and growth considerations. Antiretroviral medications are not administered for pain relief. Addiction is not a realistic concern with antiretroviral medications. Antiretroviral medications are still needed during adolescence.

What is the drug of choice the nurse should administer in the acute treatment of anaphylaxis? a. Diphenhydramine b. Histamine inhibitor (cimetidine) c. Epinephrine d. Albuterol

C Epinephrine is the first drug of choice in immediate treatment of anaphylaxis. Treatment must be initiated immediately because it may only be a matter of minutes before shock occurs. Diphenhydramine and cimetidine may be used, but the drug of choice is epinephrine. Albuterol is not usually indicated.

The most appropriate nursing diagnosis for the child with acute glomerulonephritis is a. Risk for Injury related to malignant process and treatment. b. Deficient Fluid Volume related to excessive losses. c. Risk for Imbalanced Fluid Volume related to a decrease in plasma filtration. d. Excess Fluid Volume related to fluid accumulation in tissues and third spaces.

C Glomerulonephritis has a decreased filtration of plasma. The resulting decrease in plasma filtration results in an excessive accumulation of water and sodium that expands plasma and interstitial fluid volumes, leading to circulatory congestion and edema. No malignant process is involved in acute glomerulonephritis. Excess fluid volume is found in this disease process. The fluid accumulation is related to the decreased plasma filtration.

Children receiving long-term systemic corticosteroid therapy are most at risk for which condition? a. Hypotension b. Dilation of blood vessels in the cheeks c. Growth delays d. Decreased appetite and weight loss

C Growth delay is associated with long-term steroid use. Hypertension is a clinical manifestation of long-term systemic steroid administration. Dilation of blood vessels in the cheeks is associated with an excess of topically administered steroids. Increased appetite and weight gain are clinical manifestations of excess systemic corticosteroid therapy.

Of all the signs seen in infants with respiratory distress syndrome, which sign is especially indicative of the syndrome? a. Pulse more than 160 beats/min b. Circumoral cyanosis c. Grunting d. Substernal retractions

C Grunting increases the pressure inside the alveoli to keep them open when surfactant is insufficient. This is a characteristic and often early sign of RDS. The other assessments are not specific to RDS.

Which condition is characterized by a history of bloody diarrhea, fever, abdominal pain, and low hemoglobin and platelet counts? a. Acute viral gastroenteritis b. Acute glomerulonephritis c. Hemolytic-uremic syndrome d. Acute nephrotic syndrome

C Hemolytic-uremic syndrome is an acute disorder characterized by anemia, thrombocytopenia, and acute renal failure. Most affected children have a history of gastrointestinal symptoms, including bloody diarrhea. Anemia and thrombocytopenia are not associated with acute gastroenteritis. The symptoms described are not suggestive of acute glomerulonephritis. The symptoms described are not suggestive of nephrotic syndrome.

With regard to eventual discharge of the high-risk newborn or transfer to a different facility, nurses and families should be aware that a. infants will stay in the NICU until they are ready to go home. b. once discharged to home, the high-risk infant should be treated like any healthy term newborn. c. parents of high-risk infants need special support and detailed contact information. d. if a high-risk infant and mother need transfer to a specialized regional center, it is better to wait until after birth and the infant is stabilized.

C High-risk infants can cause profound parental stress and emotional turmoil. Parents need support, special teaching, and quick access to various resources available to help them care for their baby. Parents and their high-risk infant should get to spend a night or two in a predischarge room, where care for the infant is provided away from the NICU. Just because high-risk infants are discharged does not mean they are normal, healthy babies. Follow-up by specialized practitioners is essential. Ideally, the mother and baby are transported with the fetus in utero; this reduces neonatal morbidity and mortality.

Which statement is true about large for gestational age (LGA) infants? a. They weigh more than 3500 g. b. They are above the 80th percentile on gestational growth charts. c. They are prone to hypoglycemia, polycythemia, and birth injuries. d. Postmaturity syndrome and fractured clavicles are the most common complications.

C Hypoglycemia, polycythemia, and birth injuries are common in LGA infants. LGA infants are determined by their weight compared to their age. They are above the 90th percentile on the gestational growth charts. Birth injuries are a problem, but postmaturity syndrome is not an expected complication with LGA infants.

A nurse is assessing an SGA infant with asymmetric intrauterine growth restriction. What assessment finding correlates with this condition? a. One side of the body appears slightly smaller than the other. b. All body parts appear proportionate. c. The head seems large compared with the rest of the body. d. The extremities are disproportionate to the trunk.

C In asymmetric intrauterine growth restriction, the head is normal in size but appears large because the infant's body is long and thin due to lack of subcutaneous fat. The left and right side growth should be symmetric. With asymmetric intrauterine growth restrictions, the body appears smaller than normal compared to the head. The body parts are out of proportion, with the body looking smaller than expected due to the lack of subcutaneous fat. The body, arms, and legs have lost subcutaneous fat so they will look small compared to the head.

Overstimulation may cause increased oxygen use in a preterm infant. Which nursing intervention helps to avoid this problem? a. Group all care activities together to provide long periods of rest. b. While giving your report to the next nurse, stand in front of the incubator and talk softly about how the infant responds to stimulation. c. Teach the parents signs of overstimulation, such as turning the face away or stiffening and extending the extremities and fingers. d. Keep charts on top of the incubator so the nurses can write on them there.

C Parents should be taught these signs of overstimulation so they will learn to adapt their care to the needs of their infant. This may understimulate the infant during those long periods and overtire the infant during the procedures. Talking in front of the incubator could overstimulate the baby. Placing objects on top of the incubator or using it as a writing surface increases the noise inside.

A preterm infant is on a respirator with intravenous lines and much equipment around her when her parents come to visit for the first time. What action by the nurse is most important? a. Suggest that the parents visit for only a short time to reduce their anxieties. b. Reassure the parents that the baby is progressing well. c. Encourage the parents to touch her. d. Discuss the care they will give her when she goes home.

C Physical contact with the infant is important to establish early bonding. The nurse as the support person and teacher is responsible for shaping the environment and making the care giving responsive to the needs of both the parents and the infant. The nurse should encourage the parents to touch their baby and show them how to do so safely. Bonding needs to occur, and this can be fostered by encouraging the parents to spend time with the infant. It is important to keep the parents informed about the infant's progression, but the nurse needs to be honest with the explanations. Discussing home care needs to wait until the parents are ready and discharge is closer with known needs.

Decreased surfactant production in the preterm lung is a problem because surfactant a. causes increased permeability of the alveoli. b. provides transportation for oxygen to enter the blood supply. c. keeps the alveoli open during expiration. d. dilates the bronchioles, decreasing airway resistance.

C Surfactant prevents the alveoli from collapsing each time the infant exhales, thus reducing the work of breathing. It does not cause increased permeability, provide transportation of oxygen or dilate the bronchioles.

Which intervention is appropriate for a child receiving high doses of steroids? a. Limit activity and receive home schooling. b. Increase the amount of carbohydrates in the diet. c. Substitute a killed virus vaccine for live virus vaccines. d. Monitor for seizure activity.

C The child on high doses of steroids should not receive live virus vaccines because of immunosuppression. Limiting activity and home schooling are not routine for a child receiving high doses of steroids. Children on high doses of steroids sometimes get carbohydrate intolerance; the diet should not contain high levels of carbohydrates. Children on steroids are not typically at risk for seizures.

What should the nurse include in a teaching plan for the mother of a toddler who will be taking prednisone for several months? a. The medication should be taken between meals. b. The medication needs to be discontinued if side effects appear. c. The medication should not be stopped abruptly. d. The medication may lower blood glucose.

C The dosage must be tapered before the drug is discontinued to allow the gradual return of function in the pituitary-adrenal axis. Prednisone should be taken with food to minimize or prevent gastrointestinal bleeding. Although there are adverse effects from long-term steroid use, the medication must not be discontinued without consulting a physician. Acute adrenal insufficiency can occur if the medication is withdrawn abruptly. The dosage needs to be tapered. The medication puts the child at risk for hyperglycemia.

What action does the nurse add to the plan of care for an infant experiencing symptoms of drug withdrawal? a. Keeping the newborn sedated b. Feeding every 4 to 6 hours to allow extra rest c. Swaddling the infant snugly d. Playing soft music during feeding

C The infant should be wrapped snugly to reduce self-stimulation behaviors and protect the skin from abrasions. The baby is not kept sedated. The infant should be fed in small, frequent amounts and burped well to diminish aspiration and maintain hydration. The infant should not be stimulated (such as with music), because this will increase activity and potentially increase CNS irritability.

The nurse is observing a parent holding a preterm infant. The infant is sneezing, yawning, and extending the arms and legs. What action by the nurse is best? a. Cover the infant with a warmed blanket. b. Encourage the parent to do kangaroo care. c. Encourage the parent to place the infant back in the warmer d. Have the parent fold the infant's arms across the chest.

C These are signs that the preterm infant is overstimulated. The parent should place the infant back in her warmer, and the nurse can turn down the lights and limit noise. The other suggestions will not help decrease stimulation.

Near the end of the first week of life, an infant who has not been treated for any infection develops a copper-colored, maculopapular rash on the palms and around the mouth and anus. The newborn is showing signs of a. gonorrhea. b. herpes simplex virus infection. c. congenital syphilis. d. HIV.

C This rash is indicative of congenital syphilis. The lesions may extend over the trunk and extremities. This is not characteristic of gonorrhea, herpes, or HIV.

Providing care for the neonate born to a mother who abuses substances can present a challenge for the health care team. Nursing care for this infant requires a multisystem approach. The first step in the provision of this care is a. pharmacologic treatment. b. reduction of environmental stimuli. c. neonatal abstinence syndrome scoring. d. adequate nutrition and maintenance of fluid and electrolyte balance.

C Various scoring systems exist to determine the number, frequency, and severity of behaviors that indicate neonatal abstinence syndrome. The score is helpful in determining the necessity of drug therapy to alleviate withdrawal. Pharmacologic treatment is based on the severity of withdrawal symptoms. Swaddling, holding, and reducing environmental stimuli are essential in providing care to the infant who is experiencing withdrawal. However, the scoring helps provide definitive care. Fluids and electrolyte balance are appropriate for any infant.

A primigravida has just delivered a healthy infant girl. The nurse is about to administer erythromycin ointment in the infant's eyes when the mother asks, "What is that medicine for?" The nurse responds a. "It is an eye ointment to help your baby see you better." b. "It is to protect your baby from contracting herpes from your vaginal tract." c. "Erythromycin is given to prevent a gonorrheal infection." d. "This medicine will protect your baby's eyes from drying out."

C With the prophylactic use of erythromycin, the incidence of gonococcal conjunctivitis has declined to less than 0.5%. Eye prophylaxis is administered at or shortly after birth to prevent ophthalmia neonatorum. Erythromycin has no bearing on enhancing vision and is not used for herpes infections or lubrication.

Which statement by a parent of a child with nephrotic syndrome indicates an understanding of a no-added-salt diet? a. "I can give my child sweet pickles." b. "My child can put ketchup on his hotdog." c. "I can let my child have potato chips." d. "I do not put any salt in foods when I am cooking."

D A no-added-salt diet means that no salt should be added to foods, either when cooking or before eating. Pickles of any type, hotdogs, and potato chips are all prohibited on this diet.

The infant of a mother with diabetes is hypoglycemic. What type of feeding should be instituted first? a. Glucose water in a bottle b. D5W intravenously c. Formula via nasogastric tube d. Breast milk

D Breast milk is metabolized more slowly and provides longer normal glucose levels. Breast milk is best for nearly all babies. High levels of dextrose correct the hypoglycemia but will stimulate the production of more insulin. Oral feedings are tried first; intravenous lines should be a later choice if the hypoglycemia continues. Formula does provide longer normal glucose levels but would be administered via bottle, not by tube feeding unless the baby is unable to take oral feedings.

Which clinical finding warrants further intervention for the child with acute post streptococcal glomerulonephritis? a. Weight loss to within 1 lb of the preillness weight b. Urine output of 1 mL/kg/hr c. A positive antistreptolysin O (ASO) titer d. Inspiratory crackles

D Children with excess fluid volume may have pulmonary edema. Inspiratory crackles indicate fluid in the lungs. Pulmonary edema can be a life-threatening complication. Weight loss is an indication that the child is responding to treatment. The urine output of 1 mL/kg/hr is acceptable. A positive ASO titer indicates the presence of antibodies to streptococcal bacteria; it is used to aid in diagnosis of acute post streptococcal glomerulonephritis. This is an expected finding if the child has this acute illness.

A child with secondary enuresis who complains of dysuria or urgency should be evaluated for which condition? a. Hypocalciuria b. Nephrotic syndrome c. Glomerulonephritis d. UTI

D Complaints of dysuria or urgency from a child with secondary enuresis suggest the possibility of a UTI. An excessive loss of calcium in the urine (hypercalciuria) can be associated with complaints of painful urination, urgency, frequency, and wetting. Nephrotic syndrome is not usually associated with complaints of dysuria or urgency. Glomerulonephritis is not a likely cause of dysuria or urgency.

Which combination of expressing pain could be demonstrated in a neonate? a. Low-pitched crying, tachycardia, eyelids open wide b. Cry face, flaccid limbs, closed mouth c. High-pitched, shrill cry, withdrawal, change in heart rate d. Cry face, eye squeeze, increase in blood pressure

D Cry face, eye squeeze, and an increase in blood pressure indicate pain. The other manifestations are not those of pain in the neonate.

Which intervention is appropriate when examining a male infant for cryptorchidism? a. Cooling the examiner's hands b. Taking a rectal temperature c. Eliciting the cremasteric reflex d. Warming the room

D For the infant's comfort, the infant should be examined in a warm room with the examiner's hands warmed. Testes can retract into the inguinal canal if the infant is upset or cold. A rectal temperature yields no information about cryptorchidism. Testes can retract into the inguinal canal if the infant is upset or cold or if the cremasteric reflex is elicited. This can lead to an incorrect diagnosis.

Hypospadias refers to a. absence of a urethral opening. b. penis shorter than usual for age. c. urethral opening along dorsal surface of penis. d. urethral opening along ventral surface of penis.

D Hypospadias is a congenital condition in which the urethral opening is located anywhere along the ventral surface of the penis. The urethral opening is present in hypospadias but not at the glans. Hypospadias refers to the urethral opening, not to the size of the penis. Epispadias is where the urethral opening is along the dorsal surface of the penis.

A nurse is teaching parents about the importance of immunizations for infants because of immaturity of the immune system. The parents demonstrate that they understand the teaching if they make which statement? a. "We plan to opt out of most childhood vaccinations." b. "There are only a few diseases that have effective immunizations." c. "Babies are born with a sophisticated immune system so they need few, if any, immunizations." d. "Newborns have a hard time fighting infection so they need vaccinations."

D Immaturity of the immune system places an infant and young child a greater risk of infection, so they need protection through a scheduled series of immunizations. Parents can opt out of many vaccinations, but the nurse should investigate why they plan to do so. Most communicable disease of childhood have immunizations.

A nurse is participating in a neonatal resuscitation. What action by the nurse takes priority? a. Suction the mouth and nose. b. Stimulate the infant by rubbing the back. c. Perform the Apgar test. d. Place the infant in a preheated warmer.

D In a resuscitation situation, the nurse places the newborn in a preheated warmer immediately to reduce cold stress. Next position the infant in a "sniffing" position. Suctioning is the third step. Drying the infant is fourth, although if more than one health care provider is present, drying can occur simultaneously with the other actions.

A mother with diabetes has done some reading about the effects of the condition on her newborn. Which statement shows a misunderstanding that should be clarified by the nurse? a. "Although my baby is large, some women with diabetes have very small babies because the blood flow through the placenta may not be as good as it should be." b. "My baby will be watched closely for signs of low blood sugar, especially during the early days after birth." c. "The red appearance of my baby's skin is due to an excessive number of red blood cells." d. "My baby's pancreas may not produce enough insulin because the cells became smaller than normal during my pregnancy."

D Infants of diabetic mothers may have hypertrophy of the islets of Langerhans, which may cause them to produce more insulin than they need. The other statements are correct and show good understanding.

Which diagnostic finding is present when a child has primary nephrotic syndrome? a. Hyperalbuminemia b. Positive ASO titer c. Leukocytosis d. Proteinuria

D Large amounts of protein are lost through the urine as a result of an increased permeability of the glomerular basement membrane. Hypoalbuminemia is present because of loss of albumin through the defective glomerulus and the liver's inability to synthesize proteins to balance the loss. ASO titer is negative in a child with primary nephrotic syndrome. Leukocytosis is not a diagnostic finding in primary nephrotic syndrome.

The nursing student learns that transmission of HIV from mother to baby occurs in which fashion? a. From the maternal circulation only in the third trimester b. From the use of unsterile instruments c. Only through the ingestion of amniotic fluid d. Through the ingestion of breast milk from an infected mother

D Postnatal transmission of HIV through breastfeeding may occur. Transplacental transmission can occur at any time during pregnancy. Unsterile instruments are possible sources of transmission but highly unlikely. Transmission of HIV may also occur during birth from blood or secretions. Transmission of HIV from the mother to the infant may occur transplacentally at various gestational ages. This is highly unlikely as most health care facilities must meet sterility standards for all instrumentation.

Compared to the term infant, the preterm infant has a. few blood vessels visible though the skin. b. more subcutaneous fat. c. well-developed flexor muscles. d. greater surface area in proportion to weight.

D Preterm infants have greater surface area in proportion to their weight. They often have visible blood vessels because their skin is thin and they have less fat. More fat and well- developed flexor muscles are characteristic of a more mature infant.

Which is true about newborns classified as small for gestational age (SGA)? a. They weigh less than 2500 g. b. They are born before 38 weeks of gestation. c. Placental malfunction is the only recognized cause of this condition. d. They are below the 10th percentile on gestational growth charts.

D SGA infants are defined as below the 10th percentile in growth when compared with other infants of the same gestational age. SGA is not defined by weight. Infants born before 38 weeks are defined as preterm. There are many causes of SGA babies.

A nurse is caring for an SGA newborn. What nursing action is most important? a. Observe for respiratory distress syndrome. b. Observe for and prevent dehydration. c. Promote bonding. d. Prevent hypoglycemia by early and frequent feedings.

D The SGA infant has poor glycogen stores and is subject to hypoglycemia. Respiratory distress syndrome is seen in preterm infants. Dehydration is a concern for all infants and is not specific for SGA infants. Promoting bonding is a concern for all infants and is not specific for SGA infants.

The most common cause of acute kidney injury in children is a. pyelonephritis. b. tubular destruction. c. urinary tract obstruction. d. severe dehydration.

D The most common cause of acute kidney injury in children is dehydration or other causes of poor perfusion that may respond to restoration of fluid volume. This is a prerenal cause. Pyelonephritis, tubular destruction, and urinary tract obstruction are not common causes of acute kidney injury in children.

Because of the premature infant's decreased immune functioning, what nursing diagnosis should the nurse include in a plan of care for a premature infant? a. Delayed growth and development b. Ineffective thermoregulation c. Ineffective infant feeding pattern d. Risk for infection

D The nurse needs to know that decreased immune functioning increases the risk for infection. The other diagnoses are appropriate for the premature infant but not related directly to immune function.

A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A cesarean section is performed for failure to progress. The fetal heart rate before birth is 180 beats/min with limited variability. At birth, the newborn has Apgar scores of 6 and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. Based on the maternal history, the cause of this newborn's distress is most likely a. hypoglycemia. b. phrenic nerve injury. c. respiratory distress syndrome. d. sepsis.

D The prolonged rupture of membranes and the tachypnea (before and after birth) both suggest sepsis. There is no evidence of phrenic nerve damage or respiratory distress syndrome. Early signs of sepsis may be difficult to distinguish from other problems such as hypoglycemia, but the prolonged rupture of membranes puts this baby at high risk of sepsis.

Which organs and tissues control the two types of specific immune functions? a. The spleen and mucous membranes b. Upper and lower intestinal lymphoid tissue c. The skin and lymph nodes d. The thymus and bone marrow

D The thymus controls cell-mediated immunity (cells that mature into T lymphocytes). The bone marrow controls humoral immunity (stem cells for B lymphocytes). Both the spleen and mucous membranes are secondary organs of the immune system that act as filters to remove debris and antigens and foster contact with T lymphocytes. Gut-associated lymphoid tissue is a secondary organ of the immune system. This tissue filters antigens entering the gastrointestinal tract. The skin and lymph nodes are secondary organs of the immune system.

Four hours after delivery of a healthy neonate of an insulin-dependent diabetic woman, the baby appears jittery, irritable, and has a high-pitched cry. Which nursing action has top priority? a. Start an intravenous line with D5W. b. Notify the clinician stat. c. Document the event in the nurses' notes. d. Test for blood glucose level.

D These are signs of hypoglycemia in the newborn. The nurse should test the infant's blood glucose level and then feed the infant if it is low. It is not common practice to give intravenous glucose to a newborn prior to feeding. Feeding the infant is preferable because the formula or breast milk will last longer. The provider needs to be notified after corrective action has been taken. Documentation should occur but is not the priority.

A macrosomic infant is born after a difficult, forceps-assisted delivery. After stabilization, the infant is weighed, and the birth weight is 4550 g (9 pounds, 6 ounces). What action by the nurse is most appropriate? a. Leave the infant in the room with the mother. b. Take the infant immediately to the nursery. c. Perform a gestational age assessment. d. Monitor blood glucose levels frequently.

D This infant is macrosomic (over 4000 g) and is at high risk for hypoglycemia. Blood glucose levels should be monitored frequently, and the infant should be observed closely for signs of hypoglycemia. The infant can stay with the mother, but this is not the best answer since it does not include the close monitoring needed. Regardless of gestational age, this infant is macrosomic.

Which of the following is a true statement describing the differences in the pediatric genitourinary system compared with the adult genitourinary system? a. The young infant's kidneys can more effectively concentrate urine than an adult's kidneys. b. After 6 years of age, kidney function is nearly like that of an adult. c. Unlike adults, most children do not regain normal kidney function after acute renal failure. d. Young children have shorter urethras, which can predispose them to UTIs.

D Young children have shorter urethras, which can predispose them to UTIs. The young infant's kidneys cannot concentrate urine as efficiently as can those of older children and adults because the loops of Henle are not yet long enough to reach the inner medulla, where concentration and reabsorption occur. By 6 to 12 months of age, kidney function is nearly like that of an adult. Unlike adults, most children with acute renal failure regain normal function.