Peds: Chapter 7

A new mother asks the nurse what is the expected color the infant's stool. What is an important question for the nurse to ask the mother? "Did the infant have a meconium stool yet?" "Are you breast feeding or using formula?" "Why are you worried about the stool?" "Did you see loose stool when you changed the diaper?"

"Are you breast feeding or using formula?"

The nurse is teaching parents about child abuse. What statement indicates that the parents need more education? "We will use a car seat each time we take the infant out." "I cannot get out of bed every time the infant cries during the night." "My mother is the best babysitter we have today." "I know we need to get a babysitter when we leave the house."

"I cannot get out of bed every time the infant cries during the night."

The nurse is teaching parents about preventing hypothermia with the newborn. Which statement made by the mother requires further teaching? "I will keep my baby warm and dry." "I will keep the stocking cap on the baby to prevent heat loss." "I will cover the infant with pajamas when I have him under the radiant warmer." "I can wrap the infant with two blankets."

"I will cover the infant with pajamas when I have him under the radiant warmer."

The nurse is encouraging a mother to breast feed the infant. What statements made by the mother inhibit the mother's ability to breast feed? Select all that apply. "I feel overwhelmed with the responsibility of the infant." "My baby is so special to me." "I am so tired and need to sleep." "My baby is hungry." "My breasts are hurting."

"My breasts are hurting." "I am so tired and need to sleep." "I feel overwhelmed with the responsibility of the infant."

The nurse is teaching parents about sleep patterns for infants. What parent statement requires further teaching? Select all that apply. "My newborn sleeps and then awakens for feeding." "My infant has sleep deprivation." "At 6 months, my infant will not take a nap, so I no longer put my infant down for a nap." "By age 3 months, my infant can sleep 8 hours at night." "By 1 year of age, the infant will sleep 10-11 hours at night."

"My infant has sleep deprivation." "At 6 months, my infant will not take a nap, so I no longer put my infant down for a nap."

The nurse is monitoring the newborn's respirations. What respiratory rate is most concerning for the nurse? 42 breaths per minute 48 breaths per minute 58 breaths per minute 66 breaths per minute

66 breaths per minute

The nurse assesses developmental milestones of a 2-month-old infant. What is a normally expected developmental milestone? Doubled birth weight Able to blow bubbles Begins to drool Has coordinated eye movements

Able to blow bubbles

The nurse is assisting a mother with breast feeding an infant. What does the nurse understand are late cues for breast feeding readiness? Select all that apply. Crying Rooting Stirring Agitation Head bobbing up and down

Agitation Crying

The nursery nurse is familiar with prophylactic medications for newborns. Which newborn medication has a special consideration of protecting from light? Aquamephyton Erythromycin Silver nitrate Recombivax HB

Aquamephyton

A nurse is teaching a new mother about safe techniques with bottle feeding the infant. What are safety precautions the mother will follow? Select all that apply. Microwave the formula to be sure it is warm. Wash the bottle once a day. Avoid propping the bottle. Hold the infant close during bottle feeding. Burp the infant frequently.

Avoid propping the bottle. Hold the infant close during bottle feeding. Burp the infant frequently.

A mother asks a nurse is it safe for the infant to have breast milk. What are correct statements regarding breast milk composition? Select all that apply. Breast milk has water with nutrients. Breast milk is the same for each woman. Breast milk has immunoglobulins just like formulas. Breast milk can cause an allergic response. Breast milk decreases the risk of obesity.

Breast milk decreases the risk of obesity. Breast milk has water with nutrients.

The healthcare provider preforms a red reflex examination. What specific life-altering abnormalities are being assessed? Select all that apply. Cataracts Glaucoma Jaundiced sclera Hypospadias Mongolian spots

Cataracts Glaucoma

The nurse is explaining hyperbilirubinemia interventions to a mother who is having difficulty breast feeding her infant. What intervention can the nurse try with the mother? Supplement the infant's feedings with glucose water. Consult a lactation specialist. Encourage the mother to use formula. Support the use of daily formula feedings and breast milk at night.

Consult a lactation specialist.

The infant experiences multiple stimuli that influence respirations during extra-uterine transition. What are external stimuli that influence infant respirations? Select all that apply. Acidosis Chest compression Alkalosis Cool air Touch

Cool air Touch Chest compression

The nurse is starting phototherapy with an infant with hyperbilirubinemia. Which nursing intervention would be appropriate to include with the start of therapy? Discourage breast feeding. Cover the infant's eyes with eye patches during therapy. Place the infant in a blanket under the light for warmth. Allow the parents to hold the infant to promote bonding throughout the day.

Cover the infant's eyes with eye patches during therapy.

The nurse is assessing pain with an infant. What is a common category with pain scales used with infants? Cry Blood pressure Pupil size Heart rate

Cry

The mother is asking the nurse about the benefits of breast feeding. What should the nurse respond regarding the benefit of breast feeding for the infant? Increased infant bone density Decreased likelihood of developing insulin-dependent diabetes Enhanced post-partum weight loss Decreased risk of post-partum hemorrhage

Decreased likelihood of developing insulin-dependent diabetes

A 6-month-infant is hospitalized for a fever. What are important considerations for the infant's nursing care on the pediatric unit? Select all that apply. Encourage the parents to room in. Ask the parents to leave the room for the physical examination. Tell the parents to go home at night and the nurse will check on the infant Encourage the caregiver to leave the infant's toys at home. Educate the parents that the infant may regress

Educate the parents that the infant may regress Encourage the parents to room in.

A new mother is concerned about sudden infant death syndrome. What education would be appropriate for the nurse to provide to the mother regarding prevention of this syndrome? Buy a soft, giving mattress for comfort. Have the infant sleep supine. Keep the infant in the parent's bed Prop the infant to a side-lying position for sleeping

Have the infant sleep supine.

The nurse is assessing the newborn's head after the newborn is placed in the nursery. What is the best method to assess fontanels? Have the infant lying supine. Wash the newborn's head. Have the newborn in an upright position. Measure the newborn's head circumference.

Have the newborn in an upright position.

The site for infant blood testing is different from an adult. What is the best site for utilizing capillary blood of an infant? Heel of the foot Shoulder Palm of the hand Neck

Heel of the foot

Which immunization is administered to an infant within 24 hours of birth? Diphtheria Tetanus Hepatitis B Acellular pertussis

Hepatitis B

The nurse is assessing a newborn for cold stress. What assessments confirm the newborn is experiencing cold stress? Select all that apply. Hypoglycemia Poor sucking reflex Hyperglycemia Heart murmur Tachypnea

Hypoglycemia Poor sucking reflex Tachypnea

The nurse understands that Shaken Baby Syndrome can result in infant death. What is the most important teaching aspect for a new a parent to prevent Shaken Baby Syndrome? Infants need a safe environment. Fathers cannot be left alone with infants. A parent shaking a baby will stop the crying. Frustration with parenthood is natural.

Infants need a safe environment.

When assessing a neonate, the nursery nurse suspects the infant may have hypoglycemia. What is an indication that the infant's blood glucose is less than 45mg/dL? Irritability Adequate feeding Tachypnea Tachycardia

Irritability

The nurse applies developmental theorists with nursing care of an infant. Which developmental theorist describes how an infant develops a sense of self through symbiosis and separation, or individualism? Piaget Vygotsky Erikson Mahler

Mahler

A nursing student asks the nurse to identify the name of the inborn error of metabolism that is a rare autosomal recessive disorder common in those of Mennonite descent. What response should the nurse make? Phenylketonuria Adrenal hyperplasia Galactosemia Maple syrup disease

Maple syrup disease

The nurse is explaining stages of breast milk to a group of expectant mothers. What stage of breast milk production is the nurse describing after 10 days of birth? Colostrum Transitional milk Mature milk Lactation

Mature milk

The nurse assesses developmental milestones of 11-month-infant. What is a normally expected developmental milestone? Distinguishes colors Has taste preferences May take first steps Begins to understand differences between inanimate and animate objects

May take first steps

A nurse transitioning to a pediatric unit needs to learn about care of children with pain. What are important considerations for the nurse to integrate into the new pediatric practice? Select all that apply. Pain causes increase gastric acid production. There are no pain assessment tools for children Newborns and infants are less likely to feel pain. Pain will cause changes in fluids and electrolytes. Pupils will constrict with pain in newborns and infants.

Pain causes increase gastric acid production. Pain will cause changes in fluids and electrolytes.

The nurse is assessing a newborn's reflex by placing a finger in the palm of the neonate's hand. Which reflex is the nurse assessing? Palmar grasp Plantar grasp Rooting reflex Moro reflex

Palmar grasp

The nurse hears a mother telling the infant that it is bad behavior to cry. How will the nurse guide parents about infant discipline? Select all that apply. Infants should be left alone to cry. Infants can be spoiled if you pick the infant up all the time. Infants will guide the feeding schedule. Parents should establish a set feeding routine. Parents need to keep the infant safe as mobility increases.

Parents should establish a set feeding routine. Parents need to keep the infant safe as mobility increases.

The nurse is discussing immunity with parents. Which statement supports the parent's decision to breastfeed the infant? The infant's immune system is fully developed by birth. Passive immunity is provided by breast milk. The breastfed infant has exposure to proteins and can develop allergies. The five immunoglobulins are found in breast milk.

Passive immunity is provided by breast milk.

The nurse is assessing the infant's ears. What is the correct method for examination of the infant's ear canal?" Pull the pinnae straight back and up Pull the pinnae straight back and down Use a applicator to open the ear canal Attach adhesive tape to the pinnae for a direct view

Pull the pinnae straight back and down

The nurse is educating the parents of a three-week-old infant being admitted for colic. What teaching interventions are included for the parents? Select all that apply. Reinforce that intestinal gas is not a reflection of the caregiving skills. Swaddle the infant during the crying times. Educate the parents that the colic can persist for 12 months. White noise may cause the infant to be fussier. Limit the infant's time with a pacifier.

Reinforce that intestinal gas is not a reflection of the caregiving skills. Swaddle the infant during the crying times.

The nurse is discharging an infant after circumcision. What is an important teaching guide for a caregiver to care for the circumcised infant at home? Take the gauze off the penis when you get home. Report bleeding after three days to the pediatrician. Administer sugar for pain control. Notify the pediatrician when the infant voids

Report bleeding after three days to the pediatrician.

The nurse is working with an infant as the infant takes the first breath. What infant systems undergo the most transitions to extrauterine life? Select all that apply. Respiratory system Metabolic system Hepatic system Thermoregulatory system Circulatory system

Respiratory system Circulatory system

The nurse assesses developmental milestones of a 4-month-old infant. What is a normally expected developmental milestone? Rolls from abdomen to back Begins to lift head when lying on abdomen Transfers objects from one hand to the other Has taste preferences

Rolls from abdomen to back

The nurse is assessing a newborn reflex by brushing the side of the cheek near the corner of the mouth. What reflex is being assessed? Moro Startle Rooting Sucking

Rooting

The nurse is listening to a mother of an infant say that the infant does not react to loud noises. What does the nurse suspect with a delay in response from loud noises with the startle reflex? Select all that apply. Deafness Blindness Sleeping Hypotonia Spinal cord injury

Sleeping Deafness

The nursing instructor is reviewing an infant's genitourinary system transition and assessment. What are important considerations with infant urine output? Select all that apply. Strict intake and output is needed for any infant in the hospital. Normal urine output is calculated by infant weight. In the first 48 hours of birth the infant may have stained orange or pink urine. The fetus does not produce urine. Infants are more prone to intracellular fluid loss than extracellular fluid loss.

Strict intake and output is needed for any infant in the hospital. Normal urine output is calculated by infant weight. In the first 48 hours of birth the infant may have stained orange or pink urine.

A mother asks the nurse at a wellness clinic why her infant is drooling. What assessment finding would indicate to the nurse that the infant is teething? Prolonged fussiness Sucking on the hands Presence of Epstein pearls Generalized rash

Sucking on the hands

The nurse found an asymmetrical response with the Moro reflex. What does this abnormal response indicate? Diminished stepping Weak finger grasp Slow response with sleeping Temporary injury to the brachial plexus

Temporary injury to the brachial plexus

A new mother is asking the nurse why the newborn's hands and feet are bluish. The nurse explains acrocyanosis. What statement made by the mother indicates further teaching is required? he infant having blue hands and feet for the first 24-48 hours after birth is a response to the cold environment. The blue color of the hands and feet is normal for a full term infant 24-48 hours after birth. The blue color of the hands and feet may indicate respiratory disease. The blue color of the hands and feet after 48 hours may require further cardiac testing.

The blue color of the hands and feet may indicate respiratory disease.

The nurse measures the infant's head circumference at 35 centimeters and a chest circumference at 33 centimeters. How would the nurse interpret these measurements? The infant has microcephaly. The infant has caput succedaneum. The infant has macrocephaly. The infant has normal measurements.

The infant has normal measurements.

A nurse is teaching a mother about the infant's ability to sense the mother's presence. What statement is correct regarding the infant's hearing ability? The infant knows the difference between male and female voices. The infant does not sense the mother's voice until 3 months of age. The infant has a limited sense of smell. The infant cannot differentiate the mother's voice in the womb.

The infant knows the difference between male and female voices.

The nurse is suctioning an infant after delivery. Which statement reflects the correct procedure for clearing the infant's airway? The nurse should routinely use a bulb syringe immediately after delivery to clear the infant's oral secretions. The nurse will use a bulb syringe in the corner of the mouth then suction the nose. The nurse will use a bulb syringe in the center of the mouth then suction the nose. The nurse will use a bulb syringe in the nose then suction the mouth.

The nurse will use a bulb syringe in the corner of the mouth then suction the nose.

The nurse understands that the gestational age of a fetus has an impact on survival rate. What term is used to describe the survival rate of a fetus? Viability Gestational age Strabismus Molding

Viability

A nurse is teaching a mother about advancing feeding in infants. What information will the nurse include in the teaching regarding the appropriate infant age to introduce solid foods into the diet? 2 months 4 months 6 months 8 months

6 months

The nurse applies developmental theorists with nursing care of an infant. Which developmental theorist is the nurse using with keeping a regular feeding pattern to decrease anxiety? Piaget Vygotsky Erikson Mahler

Erikson

The nurse is explaining the use of erythromycin eye ointment to the parents of a newborn. Which statements are true regarding the eye ointment prophylaxis for newborns? Select all that apply. Erythromycin is given as a series of three doses. The medication is mandated by state laws. Erythromycin prevents hemorrhagic disease. Erythromycin prevents the transmission of gonorrhea. A side effect is pain at the injection site.

Erythromycin prevents the transmission of gonorrhea. The medication is mandated by state laws.

A nurse is working with a family in a pediatrician's office. The infant is 6 months old and the mother tells the nurse that she thinks something is wrong. What are milestone concerns that the nurse needs to assess? Select all that apply. Able to raise head Able to roll from abdomen to back Floppiness No responses to loud noises Makes many-syllable vowel sounds

Floppiness No responses to loud noises

The nurse is teaching new parents about cord care. What instruction will the nurse include related to the care of the cord? Keep the cord dry. Keep the cord inside the diaper. Remove the cord in two weeks. Allow the cord to become yellow and fall off.

Keep the cord dry.

The nurse is completing an infant's skin assessment. The nurse observes a cheesy substance found in the armpits and groin. What does the nurse do with this finding? Leave the substance intact. Scrub the substance off. Alert the healthcare provider. Continue to observe for further spread.

Leave the substance intact.

The pediatric nurse uses play with providing care with a 3-month-old infant. What important concepts will the nurse be mindful about when playing with an infant? Select all that apply. Place on their stomachs for supervised play times. Use musical toys for sensory stimulation. Select any dully color toys. Read a story to the infant in a soothing voice. Put stuffed animals in the crib so the infant can play.

Place on their stomachs for supervised play times. Use musical toys for sensory stimulation. Read a story to the infant in a soothing voice.

The nurse assesses developmental milestones of a 7-month-old infant. What is a normally expected developmental milestone? Triples birth weight Develops a security object Increases height 1 inch per month Plays pat-a-cake

Plays pat-a-cake

The nurse assesses developmental milestones of a 6- to 8-month-old infant. What is a normally expected developmental milestone? Select all that apply. Plays pat-a-cake Puts feet in mouth Takes first steps Has stranger anxiety Opens mouth for spoon

Plays pat-a-cake Puts feet in mouth Has stranger anxiety

The nurse is bathing an infant born at 35 weeks. What is the gestational term for this infant? Preterm Average full term Post mature Infant

Preterm

The nurse is receiving a report from a nurse in the labor and delivery room. The neonate had an initial 3 APGAR score at birth. What does the APGAR score of 3 indicate? The score of 3 indicates the need for resuscitation. The score of 3 is normal and will increase with time. The infant had an easy extra uterine transition. The birthing process went smoothly.

The score of 3 indicates the need for resuscitation.

The nurse is receiving report from a nurse in the labor and delivery room. The neonate had a 7 APGAR score at birth and then a 9 APGAR score. What do the APGAR scores indicate? The Apgar scores indicate the neonate requires little resuscitation for adaptation to extra-uterine life. The initial score was low, and neonate needed brisk resuscitation. The scores indicate adequate adaptation. The scores indicate that the neonate had a vigorous cry at birth.

The scores indicate adequate adaptation.