Peds Ch 15
A new mother expresses concern to the nurse that her baby is crying and grunting when passing stool. What is the nurse's best response to this observation? "This is normal behavior for infants unless the stool passed is hard and dry." "This is normal behavior for infants due to the immaturity of the gastrointestinal system." "This indicates a blockage in the intestine and must be reported to the physician." "This is normal behavior for infants unless the stool passed is black or green."
This is normal behavior for infants unless the stool passed is hard and dry." Explanation: Due to the immaturity of the gastrointestinal system, newborns and young infants often grunt, strain, or cry while attempting to have a bowel movement. This is not of concern unless the stool is hard and dry. Stool color and texture may change depending on the foods that the infant is ingesting. Iron supplements may cause the stool to appear black or very dark green
Marcy asks the nurse if her 9-month-old son is drinking the recommended amount of breast milk or formula every day. What would the appropriate response be? "He needs 4 ounces every 5 hours." "He needs 3 ounces every 6 hours." "He needs 4 ounces every 4 hours." "He needs 7 ounces every 6 hours."
He needs 7 ounces every 6 hours." Explanation: This response is correct because the recommended amount of milk/breast milk for an infant 7 to 11 months old is 6 to 8 ounces every 6 to 8 hours. This should be around 32 ounces a day. The other responses do not meet the recommended daily allowance.
The danger of fluid overload developing is a potential problem in the infant receiving an intravenous infusion. For which of the following would you observe? increased pulse rate and increased blood pressure increased pulse rate and decreased blood pressure decreased pulse rate and decreased blood pressure decreased blood pressure and swelling of the feet
increased pulse rate and increased blood pressure Explanation: An increased fluid load puts excessive strain on the circulatory system, increasing pulse rate and blood pressure.
When children are not able to communicate pain verbally, the nurse can use a behavioral assessment. The nurse knows that this assessment will least likely include: cry patterns. facial expressions. sleep patterns. body movements.
sleep patterns. Explanation: Cry patterns, facial expressions, and body movements are all part of the behavioral assessment for children who are not able to self-report the pain experience. Sleep may be used as a coping mechanism for pain and therefore not be an indicator that the child has obtained relief from pain.
The nurse is caring for a 4-week-old girl and her mother. Which is the most appropriate subject for anticipatory guidance? promoting the digestibility of breast milk telling how and when to introduce rice cereal describing root reflex and latching on advising how to choose a good formula
telling how and when to introduce rice cereal Explanation: Telling the mother how to introduce rice cereal is the most appropriate subject for anticipatory guidance. Since this mother is already breast- or bottle-feeding her baby, educating her about these subjects would not inform her about what to expect in the next phase of development.
In working with infants, the nurse would expect the posterior fontanel to be closed in an infant who is which age? 3 months 1 month 3 weeks 6 weeks
3 months Explanation: The posterior fontanel is usually closed by the second or third month of life.
The nurse is caring for an infant brought to the clinic for a rash. The nurse notes a blanchable, rose-pink macular rash on the trunk. The nurse obtains the following vital signs: temperature 99.0°F (37°C), pulse 100 bpm, respiratory rate 22 breaths/minute, and oxygen saturation 100% on room air. Which question by the nurse will be most helpful when planning interventions? "Has your child had a recent fever?" "Is your child more fussy than normal?" "Do you have family history of seizures?" "Are your child's vaccinations up to date?"
"Has your child had a recent fever?" Explanation: For a child with a rash resembling roseola, it is important to ask about recent fever because the hallmark rash appears suddenly after the sharp decline in fever. This can be useful in helping the nurse determine the child needs only standard precautions. Asking about fussiness may not be helpful because many illnesses can cause the child to be more fussy than normal. Asking about history of seizures is useful, but it not the most important question to ask when the rash of roseola appears because once the fever subsides there is minimal risk of febrile seizures. Because there is not immunization for roseola, asking about vaccination status is not the most helpful
The rash in roseola is pruritic. Which measure would you teach the parent to provide comfort? Dress the child warmly to bring out the rash so that it fades quickly. Apply cool compresses to the skin to stop local itching. Discuss with the child the importance of not scratching lesions. Administer infant aspirin every 4 hours as necessary for comfort.
Apply cool compresses to the skin to stop local itching. Explanation: Rashes can be uncomfortable and irritating. Parents need to be educated on ways to relieve discomfort and to protect and maintain skin integrity. Cool compresses or cool baths will help to relieve the itching associated with the rash. Antipruritics may be necessary to help with itching. To protect the skin, the child should be instructed not to scratch the skin to alleviate itching. The child's fingernails should be kept short. Keeping the child dressed warmly will not bring out the rash any sooner. Being warm will, however, cause increased body temperature and intensify the itching. Aspirin should not be used in children as an antipyretic. There is an increased risk of developing Reye syndrome.
When performing neurological reflexes on the infant, which primitive reflex will be present longest? Moro Babinski rooting step
Babinski Explanation: Primitive reflexes are subcortical and involve a whole-body response. Selected primitive reflexes present at birth include Moro, root, suck, asymmetric tonic neck, plantar and palmar grasp, step, and Babinski. Except for the Babinski, which disappears around 1 year of age, these primitive reflexes diminish over the first few months of life, giving way to protective reflexes.
What would be a safe temperature of water to bathe baby Ryan in the tub? The water should be 125 °F. The water should be 130 °F. The water should be 135 °F. The water should be 118 °F.
The water should be 118 °F. Explanation: The water temperature in the home should be set at less than 120 °F to prevent scalding and burning during infant baths.
The nurse is examining an 8-month-old girl for appropriate development during a regular check-up. Which observation points to a developmental risk? Uses only the left hand to grasp Picks up small objects using entire hand Crawls with stomach down Cannot pull self to standing
Uses only the left hand to grasp Explanation: Favoring one hand over the other may be a warning sign that proper motor development is not occurring in the other arm or hand. Grasping small objects with the entire hand is common at 8 months and precedes the pincer grasp, which is used about 2 months later. Crawling with stomach down and being unable to pull to standing are abilities that may not occur for another 4 to 8 weeks.
The nurse caring for a hospitalized child with failure to thrive (FTT) will focus first on: assisting the child to attain adequate nutrition to demonstrate weight gain. determining the quality of the parent-child relationship. forming a positive relationship with the child. providing appropriate developmental stimulation.
assisting the child to attain adequate nutrition to demonstrate weight gain. Explanation: Attaining nutrition to promote weight gain is the primary focus. Special feeding situations and methods may be needed, such as desensitizing the child to certain food textures or beginning enteral feedings. All the other options are important in helping the child with FTT but are not the initial focus.
A nurse is providing health promotion education to a family of an infant at the family birth center. The nurse knows the parents need more education when they state which response? "I will switch to whole milk when my infant is around 6 months of age." "I will introduce soft foods for my infant around 6 months of age." "I will give my infant a drinking cup gradually around 6 months." "I will introduce new foods one at a time."
"I will switch to whole milk when my infant is around 6 months of age." Explanation: An infant can be introduced to whole milk at about 1 year of age. At this stage infants' intestinal tracts should be mature enough for whole mile, and they will be less likely to have allergic reactions. Soft food, a drinking cup, and introducing foods one at a time are all correctly stated for developmental age.
The mother of a 6-week-old infant reports she doesn't know if her child recognizes her face yet. What response by the nurse is most appropriate? "Recognition of faces and voices will come with time." "Don't worry. He knows you are his mother." "Since about 4 weeks of age your child has been able to recognize those who are around him often." "Recognition of this type begins around 8 weeks of age."
Since about 4 weeks of age your child has been able to recognize those who are around him often." Explanation: At 1 month of age the infant can recognize by sight the people he or she knows best. Telling the child's mother that this will come with time is not correct as this developmental milestone has already occurred. Telling her not to worry minimizes her questions and concerns.
The infant measures 21.5 in (54.6 cm) at birth. If the infant is following a normal pattern of growth, what would be an expected height for the infant at the age of 6 months? 27.5 in (70 cm) 29 in (74 cm) 30.5 in (77.5 cm) 32 in (81 cm)
27.5 in (70 cm) Explanation: Infants gain about 0.5 to 1 in (1.25 to 2.5 cm) in length for each of the first 6 months of life. Therefore, a 21.5-in (54.6-cm) infant adding 6 in (15 cm) of growth would be 27.5 in (70 cm). Infants grow the fastest during the first 6 months of life and slow down the second 6 months. By 12 months of age, the infant's length has increased by 50%, making this infant 32 in (81 cm) at 1 year
What action shows an example of Erik Erikson's developmental task for the infant? The infant cries and the caregiver picks the child up. The infant cries when they have a wet diaper. The infant smiles as people walk past the crib. The infant plays the game peek-a-boo.
The infant cries and the caregiver picks the child up. Explanation: Erikson's psychosocial developmental task for the infant is to develop a sense of trust. The development of trust occurs when the infant has a need and that need is met consistently. Crying with a wet diaper without a change of the diaper leads to an unmet need. Playing peek-a boo and smiling are developmental tasks that indicate a normal healthy, happy baby. These would be attributed to Piaget theory.
When assessing the vision of a 2-month-old, what would the nurse use? black-and-white checkerboard red and blue circles gray and blue animal drawings green and yellow letters
black-and-white checkerboard Explanation: For infants younger than 6 months of age, objects such as a black-and-white checkerboard or concentric circles are best because an infant's vision is more attuned to these high-contrast patterns than to colors. High-contrast animal figures such as pandas or Dalmatians also work well.
Infant development is best described by which statement? Development varies greatly from infant to infant. Development is not sequential but predictable. Development proceeds from fine to gross. Development proceeds cephalocaudally.
Development proceeds cephalocaudally. Explanation: Growth and development both proceed from head to toe, or in a cephalocaudal sequence. The baby needs first to learn to lift the head. Once that developmental milestone has been achieved then progression can occur to rolling over and then learning to sit. Development proceeds in a proximodistal fashion. Skills are learned in a gross motor fashion before developing fine motor skills. Infants may develop skills at different ages but the process is always sequential. Unless there are other problems to interfere with development, all children will develop in the same manner.
A nurse is providing health promotion education to a family of an infant at the family birth center. The nurse knows the parents need more education when they state which response? "I will switch to whole milk when my infant is around 6 months of age." "I will introduce soft foods for my infant around 6 months of age." "I will give my infant a drinking cup gradually around 6 months." "I will introduce new foods one at a time."
I will switch to whole milk when my infant is around 6 months of age." Explanation: An infant can be introduced to whole milk at about 1 year of age. At this stage infants' intestinal tracts should be mature enough for whole mile, and they will be less likely to have allergic reactions. Soft food, a drinking cup, and introducing foods one at a time are all correctly stated for developmental age.
A 3-month-old boy was diagnosed with failure to thrive. What action will be most helpful in assisting the nurse to determine if there is an inorganic cause? Observing the mother-child interaction during feeding and hygiene activities. Observing the child's interest in and ability to feed. Assessing for adequate calorie intake through recording ounces of formula consumed. Reviewing the medical records for a history of prematurity or a congenital anomaly.
Observing the mother-child interaction during feeding and hygiene activities. Explanation: Observing the mother-child interaction during feeding and hygiene activities would disclose lack of knowledge of child care, poor feeding techniques, or inappropriate maternal bonding and interaction as inorganic causes of failure to thrive. The child's lack of interest in feeding or inability to feed would indicate organic causes, as would determining that the child consumed adequate calories for age and finding a history of prematurity or congenital anomaly.
What behavioral responses to pain would a nurse observe from an infant younger than age 1? Localized withdrawal and resistance of the entire body Passive resistance, clenching fists, and holding body rigid Reflex withdrawal to stimulus and facial grimacing Low frustration level and striking out physically
Reflex withdrawal to stimulus and facial grimacing Explanation: Infants younger than age 1 become irritable and exhibit reflex withdrawal to the painful stimulus. Facial grimacing also occurs. Localized withdrawal is experienced by toddlers ages 1 to 3 in response to pain. The nurse would observe passive resistance in school-age children. Preschoolers show a low frustration level and strike out physically.
The nurse is completing an assessment on a 2-year-old child. The nurse notes the presence of a raised reddish purple spot on the back of the child's neck. Which statement about this finding is correct? Once the child has grown these lesions are usually removed by lasers. Biopsies of these areas are usually taken once the child is a teen. These lesions will normally fade as the child ages. These lesions are associated with the development of Sturge-Weber syndrome.
These lesions will normally fade as the child ages. Explanation: The lesions described are consistent with infantile (strawberry) hemangioma. They are benign and normally fade as the child ages, usually by the age of 9 years. Nevus flammeus (port-wine stain) are associated with the development of Sturge-Weber syndrome.
The pediatric nurse is assessing a 6-month-old infant for a well-child exam. Which question(s) directed to the client's mother best assesses the infant's development? Select all that apply. "How many hours per night is your baby sleeping?" "Has your baby rolled over?" "How many teeth does your baby have?" "Can your baby sit up without assistance?" "Is your baby having feeding difficulties?"
"Has your baby rolled over?" "Can your baby sit up without assistance? Explanation: The best way to assess the infant's development is to ask the mother questions regarding the infant's developmental milestones, such as asking if the baby has rolled over or if the baby is sitting up without assistance. The nurse may ask the mother the remaining question during an infant assessment; however, these are not questions directed at the infant's development.
A nurse is preparing to administer vaccines to a 4-month-old infant. Which vaccines will the nurse administer? Select all that apply. varicella Haemophilus B inactivated poliomyelitis diphtheria, tetanus, and pertussis pneumococca
Haemophilus B inactivated poliomyelitis diphtheria, tetanus, and pertussis pneumococcal The nurse will administer Hib, IPV, DTaP, and PCV to a 4-month-old infant.
A nurse is talking to and making facial expressions at a 9-month-old baby girl during a routine office visit. What is the most advanced milestone of language development that the nurse should expect to see in this child? The infant says "da-da" when looking at her father The infant squeals with pleasure The infant coos, babbles, and gurgles The infant imitates her father's cough
The infant says "da-da" when looking at her father Explanation: By 9 months, an infant usually speaks a first word: "da-da" or "ba-ba." The other answers refer to earlier milestones in language development. In response to a nodding, smiling face, or a friendly tone of voice, a 3-month-old infant will squeal with pleasure or laugh out loud. By 4 months, infants are very "talkative," cooing, babbling, and gurgling when spoken to. At 6 months, infants learn the art of imitating. They may imitate a parent's cough, for example, or say "Oh!" as a way of attracting attention.
The nurse is watching a group of infants playing in an infant room at day care. When analyzing the developmental characteristics exhibited, which infant would the nurse identify as being approximately 3 months of age? infant picking up a toy and moving it between hands infant crawling to obtain a hard-cover book infant playing peek-a-boo with a caregiver infant laying prone with a colorful toy in front
infant laying prone with a colorful toy in front Explanation: When an infant matures and grows, the infant moves through different developmental milestones. Tummy time is introduced at 3 to 4 months of age. The 3-month milestone is where the infant begins to interact with the environment. The infant begins to reach and grasp for toys, enjoys sitting and watching the environment, likes busy-boxes, and likes to be read books. The 3-month-old infant does not display dexterity skills, crawl, or play peek-a-boo. Reference:
The nurse in a community clinic is caring for a 6-month-old infant and parent. Which nursing intervention is priority? monitoring the infant's weight and height encouraging a more frequent feeding schedule obtaining the infant's current feeding pattern recommending higher-calorie solid foods
monitoring the infant's weight and height Explanation: Monitoring the infant's weight and height is the priority intervention. Ongoing assessments of growth are important so that too-rapid or inadequate growth can be identified early. With early identification, the cause can be diagnosed and the potential for further appropriate growth maximized. Encouraging a more frequent feeding schedule, obtaining the infant's current feeding pattern, and recommending higher-calorie solid foods are interventions that would be used should assessment show that the client's nutrition level does not meet body requirements.
The nurse is working closely with a premature infant who will be discharged home soon on oxygen and cardiac/respiratory monitoring. Which comments by the parents indicate that discharge instructions were understood? Select all that apply. "It's important that we continue to bathe and dress our baby like you taught us." "We feel like we know how to respond to the alarms on the equipment." "We will only let our baby's grandpa smoke in the house if we have the oxygen turned off." "We need to follow our planned feeding schedule as closely as possible." "We will refer back to our discharge instructions if we are trying to determine if we need to notify the doctor about a change in our baby."
"It's important that we continue to bathe and dress our baby like you taught us." "We feel like we know how to respond to the alarms on the equipment." "We need to follow our planned feeding schedule as closely as possible." "We will refer back to our discharge instructions if we are trying to determine if we need to notify the doctor about a change in our baby." Explanation: The nurse would educate the family on routine newborn care while considering the additional teaching regarding newborn care with the added cardiac, respiratory equipment. The parents would also need specific and detailed information regarding the alarms and how to respond to an alarm. Smoking would not be allowed at any time in the home.
The nurse comes into an infant's room on the pediatric floor. The nurse wants to try to feed the infant for the first time since her surgery. How does the nurse know what state the infant is in by what the mother says, and that it's fine to try and feed the infant? "She has been a chatterbox and smiles just like her brother." "She is so quiet today; that is not like her." "She has been crying every time someone picks her up." "She is still sleeping; I guess she is worn out."
"She has been a chatterbox and smiles just like her brother." Explanation: The best time to feed an infant is when the child is in the active alert state. This infant is talking and smiling, which shows she is calm and actively awake. In the active alert state the infant has normal respirations, limited movement, and eyes that are bright and shiny and attentive. The other choices put the infant in a crying state, quiet alert or deep sleep, or drowsing. These stages are not optimal for interacting with the child. Reference:
During a well-child visit for a 2-month-old infant, the nurse explains the need to perform a hearing screening on the child within the next few months. The child's mother reports she has not noticed any deficits and does not see the need for this being done. Which response by the nurse is indicated?
"Unfortunately hearing losses in infants are common and it is best to check hearing before your child is 6 months old to rule out problems." Explanation: Hearing screening should be performed by the age of 6 months. This will help to ensure early intervention if needed.
The nurse is teaching a new mother the proper techniques for breastfeeding her newborn. Which is a recommended guideline that should be implemented? Wash the hands and breasts thoroughly prior to breastfeeding. Stroke the nipple against the baby's chin to stimulate wide opening of the baby's mouth. Bring the baby's wide-open mouth to the breast to form a seal around all of the nipple and areola. When finished, the mother can break the suction by firmly pulling the baby's mouth away from the nipple.
Bring the baby's wide-open mouth to the breast to form a seal around all of the nipple and areola. Explanation: Before each breastfeeding session, mothers should wash their hands, but it is not necessary to wash the breast in most cases. The mother should then stroke the nipple against the baby's cheek to stimulate opening of the mouth and bring the baby's wide-open mouth to the breast to form a seal around all of the nipple and areola. When the infant is finished feeding, the mother can break the suction by inserting her finger into the baby's mouth.
The nurse is conducting a skin assessment of a newborn. The examination reveals a light pink macule on the back of the neck. The nurse understands that this is a normal variation and is most likely which type of birthmark? salmon nevus purpura nevus flammeus petechiae
salmon nevus Explanation: A light pink macule on the back of the neck is a salmon nevus or "stork bite." A nevus flammeus (port wine stain) is dark purple-red. It is a flat patch that grows with the child. Petechiae are pinpoint reddish macules that do not blanch when pressed. Purpura are large purple macules created by bleeding under the skin.