Passpoint - Infant

The nurse caring for an infant with pyloric stenosis should be alert for which classic sign or symptom?

projectile vomiting

The parent of a neonate born with a cleft lip and palate prepares to feed the child for the first time. Which parent education should the nurse reinforce as a priority of care before the parent attempts the first feeding?

proper positioning of the neonate

A 9-month-old admitted with pneumonia cries when his parents aren't holding him. He's also unable to sleep. The parents have two other young children at home and can't stay with the infant continually. Which suggestion by the nurse might help the infant sleep?

"Can one of you stay and the other one go home and care for your other children?"

A mother is concerned that she might be spoiling her 2-month-old daughter by picking her up each time she cries. Which suggestion should the nurse offer?

"Continue to pick her up when she cries because young infants need cuddling and holding to meet their needs."

A 6-week-old infant who is not breathing is brought to the emergency department by the parents. A preliminary diagnosis of sudden infant death syndrome (SIDS) is made. Which nursing intervention is a priority?

Allow the parents to see their infant.

The parent of a 6-month-old infant with atopic dermatitis asks for advice on bathing the child. Which instructions or information should the nurse give to the parent?

Bathe the infant every other day.

An infant, age 3 months, undergoes surgical repair of a cleft lip. After surgery, the nurse should use which equipment to feed the infant?

Bulb syringe with tubing

Which nursing intervention has the highest priority in the care of an infant during the first 24 hours after surgery for cleft lip?

Carefully clean the suture line after feedings using sterile technique.

An 11-month-old infant with bronchopulmonary dysplasia and a tracheostomy experiences a decline in oxygen saturation from 97% to 88%. The infant appears anxious and the heart rate is 180 beats/minute. Which intervention is most appropriate?

Suction the tracheostomy tube.

A parent, who is visibly upset, carries a 2-month-old infant into a crowded emergency department. The child appears limp and lifeless. The parent screams to the nurse for help. What is the priority action by the nurse?

Take the infant and parent to a treatment room.

When developing a plan of care for a child, the nurse identifies which Eriksonian stage as corresponding to Freud's oral stage of psychosexual development?

Trust versus mistrust

Which problem would the nurse expect to find on the care plan of a 10-month-old infant to promote coping during hospitalization?

anxiety

A nurse performs cardiopulmonary resuscitation (CPR) for 1 minute on an infant without calling for assistance. In reassessing the infant after 1 minute of CPR, the nurse finds the infant still isn't breathing and has no pulse. The nurse should then:

call for assistance.

When collecting data on an infant diagnosed with pyloric stenosis, which finding should the nurse anticipate?

decreased bowel sounds

An infant is diagnosed with bronchopulmonary dysplasia. What is a priority problem that the nurse expects to see in the plan of care?

decreased oxygen saturation

Which complications should the nurse be most concerned about in the first 12 hours of life for a neonate born with a myelomeningocele?

infection

After surgery to repair a cleft lip, an infant has a Logan bar in place. Which postoperative nursing action is appropriate?

Holding the infant semi-upright during feedings

A nurse is caring for an infant with meningitis. Which nursing action is a priority?

Maintain an adequate airway.

An infant goes into cardiac arrest. When delivering chest compressions as part of cardiopulmonary resuscitation (CPR), where should the rescuer place her fingers?

One fingerbreadth below the nipple line, directly over the sternum

Which intervention should be included in the plan of care for a 6-month-old infant with mild dehydration related to diarrhea and vomiting?

Oral electrolyte replacement solutions, breast milk, or lactose-free formula

A recent abduction of a 2-month-old infant has raised awareness of the need for security plans for hospitals. Which security measure helps ensure the hospitalized infant's security?

Placing an identification bracelet on the infant and the parent immediately on admission

A 5-month-old infant with an upper respiratory infection is brought to the clinic. The mother reports that the infant weighed 7 lb (3.2 kg) at birth. Based on the nurse's knowledge of infant weight gain, which current weight would be within the normal range for this infant?

14 lb (6.4 kg)

The nurse is caring for an infant who has undergone a surgical repair of a cleft lip. The health care provider prescribes elbow restraints. What nursing action should be included in the infant's plan of care?

Remove the restraints every 2 hours.

A nurse is reinforcing education with parents about the nutritional needs of their full-term infant, age 2 months, who is breastfeeding. Which response shows that the parents understand their infant's dietary needs?

"We won't start any solid foods now."

The nurse is caring for an infant diagnosed with thrush. Which instruction should the nurse give to a client's mother who will be administering nystatin oral solution?

Administer the drug right after meals by swabbing the mouth.

Which sexually transmitted disease is preventable through infant vaccination?

Hepatitis B

The nurse is administering medication to a 6-week-old infant. Which factor is the nurse most correct to identify as likely to decrease the infant's ability for drug metabolism?

Inefficient liver function

A neonate born 18 hours ago with myelomeningocele over the lumbosacral region is scheduled for corrective surgery. Preoperatively, what is the most important nursing goal?

Preventing infection

When administering an oral medication to an infant, the nurse should take which action to minimize the risk of aspiration?

Using an oral syringe to place the medication beside the tongue

An infant's parent gives a history of poor feeding for a few days. The nurse observes white plaques in the infant's mouth with an erythematous base. The plaques stick to the mucous membranes tightly and bleed when scraped. The nurse would suspect which condition?

oral candidiasis

The parents of a 6 month old diagnosed with a terminal brain tumor have chosen palliative care. Which interventions will be provided for this infant? Select all that apply.

pain management and comfort measures parental support enabling the parents to participate in the infant's care

Which precaution should a nurse caring for a 2-month-old infant with respiratory syncytial virus (RSV) take to prevent the spread of infection?

wear gown, gloves, and mask

A nurse is caring for a neonate who has hypospadias. His parents are asking about having the baby circumcised before discharge. When reinforcing education with the parents about their child's condition, what should the nurse tell them?

"Circumcision is delayed as the foreskin is needed for surgical correction.

An infant is brought to the emergency department and pronounced dead with the preliminary finding of sudden infant death syndrome (SIDS). Which question to the parents is most appropriate?

"How did the infant look when you found him?"

When reinforcing education with parents of an infant newly diagnosed with diabetes insipidus, which statement by the parent indicates an appropriate understanding of this condition?

"I realize that treatment for diabetes insipidus is lifelong."

A bottle-fed infant, age 3 months, is brought to the pediatrician's office for a well-child visit. During the previous visit, the nurse taught the mother about infant nutritional needs. Which statement by the mother during the current visit indicates effective teaching?

"I'm giving the baby iron-fortified formula and a fluoride supplement because our water isn't fluoridated."

A nurse is teaching the parents of an infant with clubfeet about cast care. Which statement by the father indicates the need for further teaching?

"Immunizations will have to be delayed until the casts come off."

For the last 6 days, a 7-month-old infant has been receiving amoxicillin trihydrate to treat an ear infection. Now the parents report redness in the diaper area and small, red patches on the infant's inner thighs and buttocks. After diagnosing Candida albicans, the physician prescribes topical nystatin to be applied to the perineum four times daily. Medication teaching should include which instruction?

"Inspect your infant's mouth for white patches."

The parents of a healthy 4-month-old child are seen for a well-child check-up. Which statement indicates an understanding of the recommended immunization schedule?

"My child should have the DTaP on this visit."

A parent brings her 3-month-old to the clinic for a well-baby examination. Which statement by the parent should concern the nurse?

"She's eating rice cereal and applesauce."

The mother of an infant with pyloric stenosis expresses feelings of guilt and fear that she may have caused her child's condition. Which response by the nurse is accurate?

"The cause of pyloric stenosis is unknown."

A nurse is reinforcing education for the parents of a 10-month-old infant on the correct method for instilling eardrops prescribed for the infant when discharged. Which statement by the parents indicates understanding?

"We should pull the earlobe down and back."

A client who has tested positive for the human immunodeficiency virus (HIV) gives birth to her baby. When she asks whether her baby has acquired immunodeficiency syndrome (AIDS), how should the nurse respond?

"Your baby may have acquired HIV in utero, but we won't know for sure until the baby is older."

The nurse observes the primitive reflexes of a 1-month-old infant. Which of the reflexes shown in photos below should not be present after the age of 2 months?

*** tonic neck reflex

Sudden infant death syndrome (SIDS) is one of the most common causes of death in infants. At what age is SIDS most likely to occur?

1 week to 1 year, peaking at 2 to 4 months

The charge nurse is making client care assignments. Which client is most appropriate for a licensed practical nurse?

A stable 6-month-old infant with pneumonia

The nurse assesses a neonate with esophageal atresia for signs of dehydration. Which finding should the nurse expect to see?

A sunken anterior fontanel

A 2-month-old with a history of hydrocephalus is admitted to the pediatric unit with pneumonia. The infant's respiratory status deteriorates and the physician explains to the family that the infant requires intensive care. The grandmother convinces the parents to refuse transfer and institute comfort measures. Which action should the nurse take?

Ask to speak to the parents privately without the grandmother present.

A physical therapist has instructed the nursing staff in range-of-motion exercises for an infant with torticollis. Which intervention should the nurses perform if they feel uncomfortable performing stretches that result in the infant's crying and grimacing?

Call the physical therapist.

The nurse observes small white nodules on the roof of an infant's mouth. Which term will the nurse use when describing this finding to the health care provider?

Epstein pearls

The nurse is preparing for the discharge of a neonate with a cleft lip and palate. Which nursing instruction is of highest priority?

Establish a feeding technique

A 2-month-old infant arrives in the emergency department with a heart rate of 180 beats/minute and a temperature of 103.1° F (39.5° C) rectally. Which intervention is most appropriate?

Give acetaminophen.

How should a nurse position an infant when administering an oral medication?

Held in the bottle- or breast-feeding position

A 3-month-old admitted to the pediatric unit with meningococcal meningitis has just been assessed by the registered nurse. Which nursing intervention has the highest priority at this time?

Instituting droplet precautions

The nurse would explain to the parents of a newborn with a cleft lip and palate that they will need to schedule an appointment with which specialist?

Otolaryngologist

The nurse is caring for an infant with congenital clubfoot. After the final cast has been removed, which member of the health care team will most likely help the infant with leg and ankle exercises and provide his parents with a home exercise regimen?

Physical therapist

While preparing to discharge a 9-month-old infant who's recovering from gastroenteritis and dehydration, the nurse teaches the parents about their infant's dietary and fluid requirements. The nurse should include which other topic in the teaching session?

Safety guidelines

The nurse is obtaining data from a 1-month-old infant during a routine examination at a family health center. Which method does the nurse use to test for Babinski sign?

Stroke the bottom of the foot to determine if there's fanning and dorsiflexion of the big toe.

A 9-month-old infant is scheduled for an inguinal hernia repair. The divorced parents share joint custody of the infant. What determines who can give informed consent for the procedure?

The divorce decree should specify which parent has the right to sign the informed consent form.

The nurse is gathering data for an infant experiencing a sickle cell crisis. Which finding by the nurse is most significant to determine the state of hydration?

The infant has normal skin turgor.

The parents of an infant diagnosed with hypothyroidism have been taught to count the infant's pulse. Which intervention should be reinforced in case a high pulse rate is obtained?

Withhold the medication and call the health care provider.

Which plan is most appropriate for a discharge home visit to parents who lost an infant to sudden infant death syndrome (SIDS)?

as soon after death as possible

An infant is diagnosed with a congenital hip dislocation. The nurse should expect to note:

asymmetrical thigh and gluteal folds.

Which activity should be recommended for long-term support of parents who have lost an infant due to sudden infant death syndrome (SIDS)?

attending support groups

A healthy 2-month-old infant is brought to the clinic to "get the baby shots." Health records indicate the child received hepatitis B vaccines at birth and at the 1-month well visit. Which immunizations would the nurse expect to administer at this visit? Select all that apply.

diphtheria, tetanus, acellular pertussis (DTaP) inactivated polio vaccine (IPV) Haemophilus influenzae type b (Hib) pneumococcal conjugate (PCV13) rotavirus (RV)

When reinforcing education for parents of a neonate with congenital hypothyroidism, the nurse emphasizes that the severity of the intellectual deficit is related to which parameter?

duration of the condition before treatment

The nurse is caring for a neonate suspected of having esophageal atresia. Which data collected by the nurse will correlate with this diagnosis?

inability to aspirate gastric contents

The nurse is caring for an infant with hypospadias. Which anomaly would the nurse assess the infant for that commonly accompanies this condition?

indescended testes

When collecting data on an infant, which condition would alert the nurse as a subtle sign of hypothyroidism?

lethargy

The nurse is monitoring an infant with bronchiolitis for dehydration. What intervention is the highest priority?

measuring intake and output

After an infant with a cleft lip has surgical repair and heals, the parents can expect to see which result?

minimal scarring

During an examination of a 5-month-old infant, a flat, dull pink macular lesion is noted on the infant's forehead. The nurse suspects which condition?

salmon patch

Which developmental milestone would the nurse expect an 11-month-old infant to have achieved?

sitting independently

An infant with hypothyroidism is receiving oral thyroid hormone. Which finding should alert a nurse to a potential overdose?

tachycardia, irritability, and diaphoresis

An infant who has been in foster care since birth requires a blood transfusion. Who is authorized to give written informed consent for the procedure?

the foster parent

When presenting an informational series on infant safety, which appropriate development milestone for the 4-month-old infant would the nurse stress could jeopardize the infant's safety?

turns from abdomen to back

Which finding would concern the nurse who's caring for an infant after a right femoral cardiac catheterization?

weak right dorsalis pedis pulse