test three multiple choice (69 & 71)
a client who recently gave birth to a low birth weight newborn rushes her child to the healthcare facility with frequent vomiting and diarrhea. which should the nurse monitor in this case? a. dehydration b. jaundice c. necrotizing enterocolitis d. hypoglycemia
A Rationale: In a newborn who has frequent vomiting and diarrhea, the nurse should monitor for the presence of dehydration. Dehydration rapidly develops because the baby has very little reserve fluid in the body, and this reserve is depleted quickly if the newborn is losing water from the body at such a high rate. Symptoms of necrotizing enterocolitis include lethargy, abdomi-nal distention, hypothermia, apnea, and irritabil-ity. Signs of hypoglycemia normally relate to the central nervous system and include tremors, irritability, jitteriness, a high-pitched or weak cry, and eye rolling. Jaundice results from the inability of the newborn's immature liver to handle biliru-bin. Excess bilirubin appears in the bloodstream, causing the skin to appear yellow.
a client with a previous history of syphilis infection recently gave birth. the newborn has acquired syphilis infection and has rose spots, blebs (blisters) on the soles and palms, and catarrhal discharge from the nasal mucous membrane. which intervention should the nurse implement when caring for the newborn? a. isolate the newborn and begin treatment with antibiotics as ordered b. treat the newborn with 1 to 2% aqueous solution of gentian violet c. wipe the newborn's mouth with a sterile gauze sponge after each feeding d. administer oxygen, vitamin K, anticonvulsive medications, and sedatives are required
A Rationale: Isolating the newborn and beginning treatment with antibiotics is necessary to help control the infection and prevent harmful effects on the newborn. Treating the newborn with 1% to 2% aqueous solution of gentian violet does not help in treating syphilis; this treatment is some-times used in newborns with monilial infection. Wiping the newborn's mouth with a sterile gauze sponge after each feeding does not make much of a difference to a newborn with syphilis; this procedure is, however, beneficial in newborns with monilial infection. Administering oxygen, vitamin K, anticonvulsive medications, and sedatives does not help in the management and treatment of syphilis; this is often necessary in newborns with intracranial hemorrhage.
a client has given birth in the 28th week of gestation, and her newborn is showing signs of respiratory distress syndrome (RDS). which is true for a newborn with RDS? a. RDS is caused by a lack of alveolar surfactant b. RDS is characterized by heart rates below 50bpm c.Gucocorticosteroid is given to the newborn following birth d. respiratory symptoms of RDS typically improve within a short period of time
A Rationale: RDS is a serious breathing disorder caused by a lack of alveolar surfactant. Betamethasone, a glucocorticosteroid, is often given to the mother 12-24h before a preterm birth to help reduce the severity of RDS, not to the newborn following birth. Resp symptoms in the newborn with RDS typically worsen withing a short period of time after birth, not improve. Diagnosis of RDS is made based on a chest x-ray and the clinical symptoms of increasing resp distress, crackles, generalized cyanosis, and HR exceeding 150 bpm (not below 50 bpm).
The nurse is obtaining vital signs on an 18-month-old child. What data should the nurse obtain first? a. Respiratory rate b. Heart rate c. Blood pressure d. Temperature
A Rationale: Take respirations before taking other vital signs, because you will be unable to obtain an accurate respiratory rate if a child is crying. Count the respiratory rate for 1 full minute. If you cannot obtain a respiratory rate because of crying, observe for signs of respiratory distress by checking skin color, pallor, and the presence of breath sounds.
The nurse is obtaining data from a child that will be having a surgical procedure this morning and observes the child has a cough, runny nose, and temperature of 100°F? What is the priority action by the nurse? a. Notify the surgeon of the findings b. Continue gathering data so the surgery will not be delayed c. Administer acetaminophen d. Give the child some water for the cough
A Rationale: The nurse is obtaining data from a child that will be having a surgical procedure this morning and observes the child has a cough, runny nose, and temperature of 100°F? What is the priority action by the nurse?a. Notify the surgeon of the findingsb. Continue gathering data so the surgery will not be delayedc. Administer acetaminophend. Give the child some water for the cough
a child has been admitted to the healthcare facility for surgery. the nurse observes that the child is inactive, miserable, and clutching her blanket. The nurse understands that the child is in which stage of anxiety? a. despair b. denial c. detachment d. protest
A Rationale: The nurse understands that the child is in the despair phase of separation anxiety. A child in the denial or detachment phase of separation anxiety pretends to reject family caregivers, when actually the need for caregivers is more intense than ever. A child who cries and reacts aggres-sively, demanding her family caregivers, is in the protest phase of separation anxiety.
a nurse is caring for a newborn with signs of fussiness, weight loss, and dehydration. the infant first vomited a milky substance after an initial feed, and then the vomiting was projectile. which condition do these symptoms indicate? a. pyloric stenosis b. tracheoesophageal fistula c. imperforate anus d. cleft palate
A Rationale: The symptoms are indicative of pyloric stenosis. The pyloric opening of the stomach is Answers 3Copyright © 2017, Wolters Kluwer. Workbook for Textbook of Basic Nursing, 11th edition.constricted, leading to restriction of the food pas-sage. When a tracheal fistula accompanies esopha-geal atresia, it is referred to as a tracheoesophageal fistula. The situation is life-threatening because the esophagus channels food and mucus directly into the lungs. In an imperforate anus, the baby's rectum ends in a blind pouch, causing an obstruc-tion to the normal passage of feces. Imperforate anus is suspected if the newborn does not pass a stool within 24 hours after delivery. Cleft lip is a vertical opening in the upper lip. It may appear as a notch in the lip or extend upward into the nose. Cleft lip and palate cause feeding difficulties because the newborn is unable to suck effectively. In addition, milk that goes into the mouth may be expelled through the nose.
a newborn does not begin breathing immediately after birth and begins to turn blue. The nurse recognizes this condition as: a. cyanosis b. talipes c. physiologic jaundice d. thrush
A Rationale: if the newborn does not establish initial breathing, he or she turns blue or dusky, a condition known as cyanosis. Thrush is a type of yeast infection that results in milk-like spots in the newborn's mouth. Physiologic jaundice is a condition involving an elevated bilirubin level, causing the newborn's skin to appear yellow. Talipes, or clubfoot, is a condition in which one or both feet turn out of the normal position.
the nurse notes that a newborn has not passed stool within 24h of delivery. On investigation, the healthcare provider discovers that the baby's rectum ends in a blind pouch. Which condition does this newborn have? a. imperforate anus b. pyloric stenosis c. esophageal atresia d. phenylketonuria
A Rationale: in an imperforated anus, the baby's rectum ends in a blind pouch, causing an obstruction to the normal passage of feces that must be corrected immediately. Imperforated anus is suspected if the newborn does not pass a stool within 24h of delivery.
when caring for a preterm infant, a nruse records a blood sugar level of 32 mg/dL. The nurse understands that this infant has a condition known as hypoglycemia. Which is a possible sign of this condition? a. seizures and tremors b. decreased eye movements c. slow and feeble pulse d. low-pitchdd cry and listlessness
A Rationale: signs of hypoglycemia normally relate to the CNS and include tremors, irritablity, jitteriness, listlessness, high-pitched or weak cry, and eye rolling. the newborn may be cynaotic or pale, eat poorly, and have seizures. Infants with hypoglycemia exhibit observable signs of apnea and tachycarida, not a slow and feeble pulse.
a 4yo boy, when approached by the nurse, slaps the hand away and clings to his mother. which phase of separation anxiety is the boy experiencing? a. protest b. acceptance c. despair d. denial
A Rationale: this child is demonstrating behavior that is associated with the first phase of separation anxiety, protest. in this phase, the child cries and reacts aggressively, rejecting healthcare personnel. such a reaction is normal and denotes a healthy attachment to the caregivers.
A 10yo child has just been brought to the nursing unit after abdominal surgery. Which of the following nursing interventions must the nurse perform for the child? SATA. a. assist the child to a side position b. check for return of peristalsis c. evaluate pain and discomfort d. ask the child not to move from bed e.prevent the child from deep breathing
A B C Rationale: The nurse should assist the child to a side position to prevent aspiration. The nurse should check for return of peristalsis; if bowel sounds are absent, the nurse should consult the supervisor regarding administration of fluids or ice, to prevent gas pains. The nurse should encourage the child to move her toes, ankles, and legs (if permitted) to prevent thrombophlebitis. The nurse must ask the child to breathe deeply to prevent postoperative respiratory complications. The abdominal incisional site should be supported with a bath blanket or pillow during the process.
a nurse is assessing a toddler during a well-child visit. What should the nurse document and assess? SATA. a. play patterns and activities b. age of weaning c. language development d. tone and pitch of cry e. response to painful procedures
A B C Rationale: during the well-child visit, the nurse should assess and document the play patterns and activities, age of weaning, and the language development of the child. tone and pitch of cry and response of the child to painful procedures as assessed and documented when assessing an infant.
A preterm newborn is receiving gavage feeding every 2 hours. What action by the nurse is a priority while these feedings are being administered? Select all that apply. a. Monitor caloric intake. b. Refrigerate the formula. c. Obtain daily weights. d. Monitor intake and output. e. Increase the amount if the newborn is still hungry.
A C D Rationale: Formula is prescribed in very small amounts on a 2- to 3-hour schedule, to avoid distending the newborn's small stomach or adding to respiratory distress. Caloric intake needs to be monitored. Daily weights, and constant monitoring of intake and output are crucial. The nurse should never increase the amount of the feeding without the primary care provider orders. The formula should be given at room temperature. The newborn has an immature temperature regulating system and if the formula is refrigerated, it may cause hypothermia.
a nurse is evaluating the respiratory status of a child. which of the following symptoms may indicate pediatric respiratory distress? SATA. a. head bobbing b. fever c. nasal flaring d. wheezing e. running nose
A C D Rationale: Head bobbing, nasal flaring, and wheezing may indicate pediatric respiratory distress. Fever and a running nose are not indicative of a respiratory problem; they could indicate the flu.
a client just delivered a preterm baby in the 30th week of gestation. The nurse knows which nursing measures will be performed for this infant? SATA. a. dress the baby in a stockinette cap b. dress the baby in outfit provided by the mother c. carry and handle the baby frequently d. place the baby under isolette care e. estimate the urinary flow by weighing the diaper.
A D E Rationale: the nurse should dress the baby in a stockinette cap, place the baby under isolette care, and estimate the urinary flow by weighing the diaper. controlling the temp in high-risk newborns is often difficult; therefore, special care should be taken to keep these babies warm by dressing them in a stockinette cap and recording their temp often. Isolette care stimulates the uterine environment as closely as possible, thus maintaining even levels of temp, humidity, and oxygen for the child. the isolette is transparent, so the newborn is visible at all times. the kidneys of preterm infants are not fully developed; hence, they may have difficulty eliminating wastes. the nurse should determine accurate output by weighing the diaper before and after the infant urinates. The diaper's weight difference in grams is approx equal to the number of mLs voided. frequently carrying and handling the baby should be avoided so that the infant can conserve energy. Generally, preterm newborns in the high-risk category are not dressed, so the attending nurse can observe their breathing.
a nurse is caring for a preterm newborn with an intracranial injury. The nurse knows which nursing measures are appropriate in the care of this client? SATA. a. administering anticonvulsive medications and sedatives b. initiating breastfeeding or bottle feeding in the newborn c. irrigating the eyes with normal saline solution d. administering vitamin K IM soon after birth e. positioning the baby with the head of the bed elevated
A D E Rationale: to prevent hemorrhage, every newborn receives vitamin K IM soon after delivery, to aid in blood clotting. The child is positioned with the head of the bed slightly elevated to decrease intracranial pressure via gravity flow. Administration of oxygen, vitamin K, antibiotics, anticonvulsive medications, and sedatives is performed as ordered. The nurse hould not initiate breastfeeding or bottle feeding in the newborn. The nurse should feed a newborn with intracranial hemorrhage using a gavage tube. Irrigating the eyes with Normal saline is unnecessary. It is typically done to retain moisture in the eye in the newborns who have a facial paralysis and not in cases of intracranial hemorrhage.
when assessing the condition of a preterm baby, the nurse notices a deep crease that runs horizontally across the infant's hands. the baby has slanted eyes and a large protruding tongue. which condition should the nurse suspect in such a child? a. anencephaly b. down syndrome c. spina bifida d. hydrocephalus
B Rationale: Infants with Down syndrome may show a single deep crease running horizontally across the hands. Their eyes are slanted, and their tongue is large and protruding. The infant is flac-cid and usually exhibits signs of mental retarda-tion, heart defects, cataracts, and gastrointestinal disorders. In children with anencephaly, part or all of the brain is missing. The skull is flat, and these newborns live for only a short time, if at all. Spina bifida is a congenital neural tube defect in which the vertebral spaces fail to close, allowing a hernia-tion (bulging) of the spinal contents into a sac. Hydrocephalus is an excess of cerebrospinal fluid (CSF) in the ventricles and subarachnoid spaces of the brain, which leads to bulging fontanels and nervous irritability.
a nurse is caring fora 2 day old infant with signs of seizures, resp distress, cyanosis, a shrill cry, and muscle weakness. the child is diagnosed with intracranial hemorrhage. which procedure must the nurse employ when caring for the child? a. position the head of the bed slightly lowered b. administer vit. K immediately c. subject the newborn to phototherapy d. avoid using a gavage tube for feeding
B Rationale: Newborns with intracranial hemor-rhage are administered vitamin K intramuscularly immediately after birth to control the bleeding by enhancing clot formation. The newborn should not be positioned with the head of the bed lowered, because doing so increases the intracra-nial pressure due to the intracranial hemorrhage. Instead, the newborn with intracranial hemor-rhage should be positioned with the head of the bed slightly elevated. The infant may require administration of oxygen, vitamin K, antibiotics, anticonvulsive medications, and sedatives as ordered. Feeding in newborns with intracranial hemorrhage is usually through a gavage tube. Phototherapy is the use of ultraviolet light to treat conditions such as jaundice in newborns; it is not used for management of intracranial hemorrhage.
a 19yo client gave birth to a postterm newborn at the healthcare facility. the baby's weight is below the 10th percentile for gestational age. how should this newborn be classified? a. very low birth weight infant b. small for gestational age infant c. normal birth weight infant d. large for gestational age infant
B Rationale: Small for gestational age (SGA) indi-cates an infant whose birth weight is below the 10th percentile expected for that gestational age. Very low-birth-weight (VLBW) infants are those weighing between 1 and 3.5 lb (500 to 1,499 g). Normal-birth-weight infants are usually born between the 37th and 41st week of gestation. Macrosomic neonates, or large-for-gestational-age (LGA) neonates, are those newborns whose birth weight exceeds the 90th percentile of newborns of the same gestational age.
n Rh-negative woman who did not receive antenatal care gives birth to an Rh positive newborn. When should the nurse administer the RhoGAM to the mother? a. It is not necessary to administer the RhoGAM because the delivery was normal. b. Within 72 hours after delivery c. When the mother returns for her first postpartum appointment in 2 weeks d. After becoming pregnant with her next child within 12 weeks
B Rationale: The Rh-negative woman receives anti-D gamma globulin or RhoGAM prophylactically at 28 weeks of gestation, following any invasive procedure, for example, amniocentesis or any abortion. It is also important to give RhoGAM within 72 hours following delivery of an Rh-positive baby. Some cases of erythroblastosis fetalis still occur in women who did not have antepartal care or who did not receive RhoGAM following a previous abortion. Although the delivery may have been without complications, it is still necessary to administer the RhoGAM.
a nurse is caring for a newborn notices an abnormal breathing pattern. the newborn shows signs of dyspnea and cyanosis along with tachycardia and an expiratory grunt. what does the nurse suspect is the condition for this newborn? a. fetal alcohol syndrome b. respiratory stress syndrome c. down syndrome d. congenital rubella syndrome
B Rationale: The characteristics are suggestive of respiratory distress syndrome (RDS) caused due to deficiency of a pulmonary surfactant in the lungs. Infants with RDS exhibit signs of abnormal breath-ing, dyspnea, cyanosis, increased respiratory rate, and flaring of the nares (nostrils). The chest muscles retract during inspiration, and the condition is accompanied by tachycardia and an expiratory grunts. Fetal alcohol syndrome is characterized by growth deficiency, microcephaly, facial abnormalities, cardiac anomalies, and mental retardation. Congenital rubella syndrome is caused by rubella virus in newborns. It can cause cataracts, deafness, congenital heart defects, cardiac disease, and mental retardation. Down syndrome is characterized by a single deep crease running horizontally across the hands, slanted eyes, a large and protruding tongue, mental retardation, heart defects, cataracts, and gastroin-testinal disorders.
The nurse is caring for a hospitalized child and observes the child's behavior as apathetic and sad. What phase of separation anxiety does the nurse recognize the child is experiencing? a. Protest b. Despair c. Denial d. Anger
B Rationale: The child who appears sad or apathetic is demonstrating despair. Protest takes the form of crying and rejection of new caregivers. Denial has the appearance of resolved stranger anxiety because the child may seem to identify and accept the new environment and staff while seeming to deny and avoid parental attention. There is no phase of anger during this experience.
which should the nurse do when taking the blood pressure of a child? a. ensure that the width of the cuff is half the width of the child's arm b. ensure that the bladder of the cuff encircles the arm without overlapping c. know that thigh pressure is approx. 10 mm Hg higher than arm pressure d. know that radial blood pressure is 20 mm Hg lower than that of the brachial artery
B Rationale: The nurse should ensure that bladder of the cuff encircles the child's arm without overlapping. The nurse should ensure that the width of the cuff is approximately two-thirds of the upper arm, and not half the width of the child's arm. The nurse must know that thigh pressure is approximately 20 mm Hg higher and not 10 mm Hg higher than arm pressure. The nurse must know that radial blood pressure is 10 mm Hg lower and not 20 mm Hg lower than that of the brachial artery.
a nurse is caring for an 8yo child with diarrhea. which intervention should the nurse perform when caring for the child? a. observe the feet for signs of edema b. observe the child for skin excoriation c. take the rectal temp for accuracy d. provide plenty of solids to prevent dehydration
B Rationale: The nurse should observe the child for skin excoriation when caring for the child with diarrhea. The nurse should observe the child for signs of dehydration and not edema. Rectal temperature should not be taken for a child with diarrhea; a tympanic or oral temperature should be taken. A child with diarrhea should be given plenty of liquids that can be easily absorbed by the system to overcome dehydration.
a 4yo child at the healthcare facility is on IV therapy following diarrhea. Which method should the nurse use to determine the body temp of this child? a. rectal temp b. tympanic temp c. oral temp d. axillary temp.
B Rationale: the nurse should take a tympanic temp for the child. rectal temp should not be taken in a child with diarrhea. Oral temp is taken for children older than 6. the axially method should only be used if no other method is available.
The nurse is discussing behavior patterns with the parents of a toddler. Which issues should the nurse include in the discussion? Select all that apply. a. Aggressive behavior b. Separation anxiety c. Sibling rivalry d. Negativism e. Temper tantrums
B D E Rationale: The behaviors that the nurse should discuss with the parents that are typical issues for the growth and development of a toddler include separation anxiety, negativism ("no" is a toddler's most used word), and temper tantrums. Erikson bases these issues on the stage of autonomy versus shame and doubt, which is demonstrated by the behaviors. Aggressive behavior and sibling rivalry are exhibited behaviors in the preschool stage of growth and development.
A preschool child requires hospitalization and states, "I want my mom and dad to stay with me!" What is the best response by the nurse? a. "You will be okay by yourself. We will take care of you." b. "Be good and let us do what we need to do so you can go home with your parents." c. "You can have your parents stay with you if they are able to." d. "Your parents can stay until bedtime."
C Rationale: Healthcare personnel encourage family caregivers to remain with children during their hospital experience. Participation in care by family members promotes a less-stressed child and parent. If family members are unable to remain with their children, caregivers should assure the children that they would return. The other options are not therapeutic responses to the child's fears.
a 35yo client is overdue for delivery by 3 wks. which assessment does the nurse expect to find in the postterm newborn? a. the infant's skin may appear wet and smooth b. excess vernix caseosa may be seen on the skin c. the infant may have aspirated meconium into the lungs d. the neonate may appear large for gestational age
C Rationale: Postterm newborns are at a higher risk of swallowing meconium or aspirating it into their lungs in utero or at birth. This occurs if the first breath is taken before suctioning; the newborn may aspirate meconium and amniotic fluid into the lungs. Postterm newborns are not necessarily in better condition than full-term newborns. They often have long fingernails and hair, and dry, parched skin, not wet, smooth skin. There is usually no vernix caseosa. These babies look wrinkled and old at birth. Postterm babies often have respiratory or nutritional problems because the placenta is unable to provide adequately for them after the normal gestation period. As a result, they may be small and not large for gestational age.
which intervention should the nurse perform with regard to an infant's bath? a. provide a tub bath every day b. wash the eyes after washing the face c. provide daily shampoo to prevent cradle cap d. probe the outer ear canals of the infant
C Rationale: The nurse should provide a daily shampoo to prevent cradle cap. Some children need a shampoo daily to prevent seborrhea, a scaly scalp condition known as cradle cap. The nurse need not provide a tub bath every day; instead, the nurse should wash the child's face, hands, and diaper area daily. The nurse should clean the eyes first with clear water from the inner to the outer canthus, using a separate cotton ball for each eye, and then wash the rest of the baby's face. The nurse should not probe the outer ear canals of the infant.
a nurse is assessing a 26yo pregnant client with a Hx of marijuana and alcohol abuse. Which complication of such abuse should the nurse warn the client about? a. postterm birth b. hypoglycemia c. low birth weight d. prolonged labor
C Rationale: The nurse should warn the client that marijuana and alcohol abuse increases the risk of giving birth to a low-birth-weight child. Marijuana abuse does not prolong labor; using marijuana during pregnancy can actually precipitate labor of fewer than 3 hours. Marijuana abuse does not lead to postterm birth because marijuana use during pregnancy can actually shorten the gestation period, thereby leading to a preterm birth. Hypoglycemia does not usually develop in the newborn of the client with a history of marijuana and alcohol abuse; hypoglycemia is an important finding in large-for-gestational-age infants, who are most often born to mothers with diabetes.
a newborn develops bilateral conjunctivitis soon after birth. the nurse would assess for which maternal diagnosis? a. herpes simplex virus b. syphilis c. gonorrhea d. HIV
C Rationale: if the organism causing gonorrhea gets into the newborn's eyes during delivery, it causes a bilateral conjunctivitis. if untreated, this condition can lead to blindness.
when measuring the weight of a child, the nurse should document the weight using which unit? a. milligrams b. ounces c. kilograms d. prounds
C Rationale: measure and document the child's weight in kilograms, as this allows accurate dosage calculation for medication administration, particularly for IV fluids. Pounds, ounces, and milligrams are not appropriate units to use. however, you may want to convert the Kg to pounds for the benefit of family caregivers.
a client has given birth to a low weight baby boy. The client notices that the infant's feet are turned out of the normal position and asks the nurse if the baby is okay. The nurse knows which condition is indicated? a. polydactylism b. down syndrome c. talipes d. spina bifida
C Rationale: talipes, also known as clubfoot, is a developmental condition characterized by the turning out of one or both feet out of the normal position. the presence of an extra finger or toe is called polydactylism. often the extra digit hangs limp and boneless. spina bifida is a congenital neural tube defect. down syndrome, also called trisomy 21, is a genetic disorder often associated with mothers who give birth after age 40.
What observations by the nurse would indicate that a newborn may be "late premature"? Select all that apply. a. Increased amount of subcutaneous fat b. Lack of vernix caseosa c. Presence of lanugo on face, back, arms, and legs d. Diminished reflexes e. Respirations irregular and weak
C D E Rationale: A category called late preterm occurs between weeks 34 and 37. The preterm infant appears thin, with minimal subcutaneous fat. Lanugo (fine hair) may appear on the face, back, arms, and legs. Skin is transparent and breast tissue is barely palpable. In male newborns, the testes may be undescended. Breathing is irregular and weak. Body temperature is frequently subnormal, and the baby's cry is weak. Neurologic assessments reflect an immature central nervous system, as demonstrated by diminished or absent reflexes. Vernix caseosa is usually abundant in the preterm newborn and diminished to nonexistent in the postterm newborn.
Which of the following interventions should the nurse consider when administering medications to a child? SATA. a. tell the child that she has been "good" b. reassure the child that an injection will not hurt c. reassure the child that crying is okay d. keep the time of administration to a minimum e. ensure accuracy in medication administration
C D E Rationale: When administering medication to a child, the nurse should reassure the child that crying is okay, keep the time of administration to a minimum, and ensure accuracy in medication administration. The nurse should not tell the child that she has been "good" or reassure the child that an injection will not hurt; this would mean that the nurse may have to lie to the child.
a new mother is nervous because her infant's pulse is "really fast". the nurse explains that which range is typical for an infant HR? a. 70-115 b. 80-140 c. 60-90 d. 80-180
D Rationale. the nurse should explain to the new mother that 80-180 is the normal range for infants HR, so she has no reason to be concerned. toddlers have a normal HR of 80-140, preschoolers 70-115, and school age children 65-110, and adolescents 60-90.
A newborn in the nursery begins to have greenish-yellow foul-smelling diarrhea. What is a priority action by the nurse? a. Supplement the next feeding with formula. b. Insert a gavage feeding tube. c. Take a rectal temperature. d. Isolate the newborn.
D Rationale: Bacteria most commonly cause diarrhea, although an incompatible formula or an allergy may also be the culprit. In newborn diarrhea, the stool is formless, greenish-yellow, and foul smelling. Evidence of diarrhea requires isolation of the baby to prevent possible infection of other newborns. Obtain stool cultures. The primary care provider should be notified prior to any further feedings. It is not necessary to insert a gavage feeding tube at this time. A rectal temperature is not indicated when a newborn has diarrhea since it may irritate the rectal mucosa.
mother with diabetes delivers a macrosomic newborn by caesarian section because the newborn is too large to deliver vaginally. What is a priority for the nurse to monitor in this newborn? a. Vomiting b. An inability to immediately pass a meconium stool c. The presence of hyperthermia d. The presence of hypoglycemia
D Rationale: Elevated blood glucose levels in the mother increase the glucose available to the fetus, which stimulates additional insulin production by the fetal pancreas. When the baby is delivered, often by cesarean section, the supply of excess glucose is suddenly terminated. This newborn quickly uses all available carbohydrates and may develop hypoglycemia. Poor glucose control in the fetus increases the risk of intrauterine death and hypoglycemia in the newborn can occur suddenly. Vomiting in a newborn may indicate a congenital disorder such as esophageal atresia. It is not abnormal for an infant not to pass a meconium stool immediately after delivery and may take up to 24 hours. Hyperthermia is not likely in a newborn because they have immature temperature regulating systems and they would be more susceptible to hypothermia from conduction, convection, and evaporation.
when caring for a preterm newborn, the nurse notices milk like spots or monilial infection in the newborn's mouth. which nursing consideration should the nurse employ when caring for the newborn? a. use an antibiotic solution to swab the affected area b. administer humidified oxygen to the newborn. c. maintain the newborn on parenteral nutrition d. isolate the newborn and treat with nystatin
D Rationale: The newborn with a monilial infection is isolated and treated with nystatin, because the infection can spread through contact. Administer-ing humidified oxygen is not necessary in the newborn, because thrush is a localized condition that does not affect the respiratory system of the newborn or alter breathing. Swabbing of the infant's mouth with an antibiotic agent does not help in the treatment of the condition, because thrush is a fungal infection caused by yeast, and the antibiotic agent will not have any effect on the condition. Parenteral feeding of the newborn is unnecessary because the condition is not so severe that it affects feeding or alters other functions in the newborn.
a nurse in the pediatric unit of the healthcare facility may be required to assist in resuscitating a child. which should the nurse know if required to assist in the procedure? a. emergency drugs are calculated according to the child's age b. drugs are administered based on the circumference of the child's head c. a Broselow tape is used to measure the circumference of the child's chest d. The Broselow system of length may be substituted for weight
D Rationale: The nurse should know that the Broselow system of length may be substituted for weight in an emergency. Emergency drugs are calculated according to a child's body weight and not by age or the circumference of the child's head. The Broselow tape is a color-coded system that facilitates the use of correct pediatric drug calculations; it is not used to measure the circumference of the child's chest.
which should the nurse do when applying the clove hitch restraint to a child? a. apply the restraint directly to the arm b. check the extremity every 2h c. take off the restraint every 4h d. tie a knot when applying the device
D Rationale: The nurse should tie a knot when applying the device so that it does not become too tight. The nurse should not apply a restraint directly on the arm but should apply padding under the restraint to reduce skin irritation. The nurse should check the extremity hourly, and not every 2 hours, for circulation and signs of skin breakdown. The nurse should remove the restraint every 2 hours and allow the child to exercise the extremity.
which infection appears as milk-like spots in a newborn's mouth? a. rubella b. toxoplasmosis c. cytomegalovirus d. thrush
D Rationale: Thrush (also known as monilial infection) is a yeast infection in which milk-like spots form in the newborn's mouth. The virus of rubella can cause fetal defects, known as congenital rubella sundrome, including cataracts, deafness, congenital heart defects, cardiac disease, and mental retardation. The protozoa responsible for toxoplasmosis are found in cat feces and in rare or raw meat. Possible fetal effects include stillbirth, premature delivery, microcephaly, hydrocephaly, seizures, and mental retardation. Cytomegalovirus, a member of the herpex virus group, can result in small-for-gestational-age size, microcephaly hydrocephaly, and mental retardation in the newbonr.
a nurse is caring for a child with an oral temp of 103F. Which intervention should the nurse follow when providing a sponge bath to the child? a. check the child's temp q 30min b. add alcohol or ice for the tepid sponge bath c. maintain the water temp at 70F - 85F d. stop the sponge bath if the child shows signs of chilling
D Rationale: When caring for a child with an oral temperature of 103°F, the nurse should stop the sponge bath if the child shows signs of chilling. The nurse should check the child's temperature every 10 to 15 minutes, not every 30 minutes. The nurse should not add alcohol or ice to the sponge bath, because this could lead to hypothermia. Alcohol fumes are irritating and may be inhaled or absorbed through the skin. The nurse should maintain the temperature of the water at 85°F to 95°F, not 70°F to 85°F.
the nurse is caring for a pediatric client. Which assessment finding would alert the nurse to assess further for respiratory concerns? a. bradycardia b. drowsiness c. deep, slow breath d. nasal flaring
D Rationale: nasal flaring is a sign of pediatric respiratory distress, along with restlessness (not drowsiness), apprehension, panic, tachycardia or fast HR (not bradycardia, or slow HR), tachypnea or fast resp rate, wheezing, stridor, change in color, expiratory grunt, retractions, gasping, shallow and labored breaths (not deep, slow breaths), and head bobbing.
the nurse is reviewing feeding options for a pediatric client. the nurse knows which equipment is the preferred method for feedings in the pediatric population. a. TPN b. PICC c. external tube d. gavage button
D Rationale: sometimes, children are fed through a gavage or gastrostomy button, which is used because it is less bulky and more comfortable than an external tube. the gavage button is relatively flat on the child's abdominal wall and connects to a tube that leads into the child's stomach. a peripherally inserted central catheter (PICC) line is an intravenous method of accessing blood specimens, infusing IV chemo or antibiotics, and delivering total parenteral nurtition (TPN). however, these are bulkier and less comfortable than the gavage button.
a nurse is documenting the vital signs of a preschool-age child. what should the nurse remember when obtaining the child's pulse? a. count the pulse for 30sec b. use a standard sized stethoscope c. take the apical pulse d. take the radial pulse
D Rationale: the nurse should take the radial pulse for children older than 2 years of age. The apical pulse is taken for children younger than 2 years of age. Pulse should be counted for a full minute.
a nurse is preparing to administer an enema to an infant. which should the nurse do when administering an enema? a. use strong pressure to squeeze the container b. provide a tap-water enema c. give a warm disposable enema d. use a rubber-tipped bulb syringe
D Rationale: the nurse should use a rubber-tipped bulb syringe when administering an enema to an infant. then nurse should not use a tap-water enema as it can cause fluid and electrolyte imbalances and dehydration. the nurse should not use strong pressure to squeeze container; the pressure in the fluid can cause tissue damage. the nurse should provide disposable enemas at room temp.
a nurse has to apply a jacket device to a child at the healthcare facility. Which should the nurse do when applying the restraint to the child? a. tie the straps to the side rails of the bed b. check the child's circulation every 3h c. apply the device under clothing, against the skin d. cross the straps in the front and tie at the back.
D Rationale: when applying a jacket restraint to the child, the nurse should cross the straps in the front and tie at the back to prevent the child from getting caught in the straps and choking or strangling. The straps should not be tied to the side rails of the bed so that the rails can be raised or lowered without tightening or loosening restraints. The nurse should check the child's circulation every 1-2h and not every 3h; the child should be allowed to exercise. to reduce skin irritation, the jacket restraint should be applied over clothing or a gown and not directly over the body.
a newborn is born with symptoms of growth deficiency, microcephaly, facial abnormalities, cardiac abnomalies, and cognitive challenge. the nurse suspects that the mother likely abused with drug during her pregnancy? a. marjuana b. cocaine c. heroin d. alcohol
D Rationale: maternal use of alcohol is a major factor contributing to fetal physical defects. the resulting condition is called fetal alcohol syndrome (FAS). Effects of FAS include growth deficiency, microcephaly, facial abnormalities, cardiac anomalies, and mental retardation. although maternal use of the other listed drugs can affect the newborn, none of these cause the physical defects that appear in FAS.
