Evolve Infants

What assessment finding in a newborn is suggestive of cystic fibrosis? 1 Rapid heart rate 2 Excessive crying 3 Sternal retractions 4 Abdominal distention

4

A mother brings her 9-month-old infant to the clinic. The nurse is familiar with the mother's culture and knows that belly binding to prevent extrusion of the umbilicus is a common practice. The nurse accepts the mother's cultural beliefs but is concerned for the infant's safety. What variation of belly binding does the nurse discourage? 1 Coin in the umbilicus 2 Tight diaper over the umbilicus 3 Binder that encircles the umbilicus 4 Adhesive tape across the umbilicus

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An infant with bronchiolitis caused by the respiratory syncytial virus (RSV) is admitted to the pediatric unit. What does the nurse expect the prescribed treatment to include? 1 Humidified air and adequate hydration 2 Postural drainage and oxygen by hood 3 Bronchodilators and cough suppressants 4 Corticosteroids and broad spectrum ATBs

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The hypertonicity of the muscles in an infant with cerebral palsy causes scissoring of the legs. The nurse teaches the mother that the preferred way to carry the infant is in a sitting position: 1 Astride one of her hips 2 Strapped in an infant seat 3 Wrapped tightly in a blanket 4 Under the arm in a football hold

1 Carrying the infant astride the parent's hip prevents scissoring by keeping the infant's legs abducted. An infant seat will not prevent scissoring. Tight wrapping maintains the infant's legs in a scissored position. When the football hold is used, the infant is carried in a supine position with the legs adducted, which promotes scissoring.

A nurse is selecting toys for a 5-month-old infant. Which toy should not be given to the infant? 1 Large snap beads 2 Soft stuffed animals 3 Rattles that can be held 4 Brightly colored mobiles

1 Fine motor coordination is developed inadequately for manipulation of snap toys. Soft stuffed animals stimulate the sense of touch, and because voluntary grasp appears at about 3 to 4 months they can be handled satisfactorily. The voluntary grasp will allow the child to hold a rattle, and the rattling sound will stimulate the auditory system. Bright mobiles are appropriate to stimulate visual attention.

A 2-month-old infant is to have a nasogastric tube inserted. The nurse expects that: 1 A pacifier will be offered to lessen gagging and allow easier insertion of the tube. 2 Gastric contents will not appear in the tube if the infant is receiving nothing by mouth. 3 The tube will be passed a distance equal to the length from the chin to the tip of the sternum. 4 Coughing, irregular breathing, and slight cyanosis will occur during introduction of the tube.

1 Sucking and swallowing (the infant's response to a pacifier) reduce gagging and facilitate the insertion of the nasogastric tube. A small amount of gastric fluid is always present and will appear in the tube. The tube is passed the distance from the ear to the tip of the nose to the distal end of the sternum. Coughing, gagging, and cyanosis are indications that the tube has passed into the larynx, not the stomach.

A nurse is caring for an infant who is to undergo surgery for hypertrophic pyloric stenosis (HPS). The nurse explains to the parents that this type of surgery has a high success rate when the infant's physical status meets certain criteria. What specific criterion should be discussed with the parents? 1 Vomiting is not yet severe and projectile. 2 fluid and electrolyte imbalances are corrected. 3 Small feedings of thickened formula are tolerated. 4 Amount of drainage from gastric decompression is sufficient.

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A 2-month-old infant is admitted to the pediatric unit for observation after an automobile collision. Family members are unable to stay. How can the nurse best provide psychological comfort for the infant? 1 Assigning the same nurse to the infant 2 Following a routine to which the infant is accustomed 3 Having the infant listen to the parents' voices over the phone 4 Ensuring that a staff member stays with the infant at all times

2 Very young infants gain security from having their needs met consistently. Assigning one nurse to care for the infant is ideal but unrealistic. It is not critical at this age because the infant does not yet seek security from a significant caregiver. Although the infant may recognize the parents' voices, having the parents phone the child will not ensure psychological comfort. Consistent observation is adequate.

A 2-month-old girl is admitted to the pediatric unit in heart failure. The practitioner prescribes nothing-by-mouth status and the semi-Fowler position. How should the nurse obtain the infant's weight? 1 Weighing the infant quickly in the supine position 2 Asking the mother for the infant's most recent weight 3 Placing the infant in an infant seat, recording the weight, and then subtracting the weight of the seat 4 Having the mother hold the infant, weighing them both, and then subtracting the weight of the adult

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If a 5½-month-old infant's immunizations are on schedule, which immunizations does the nurse expect the infant to have had already? 1 Measles, mumps, and rubella vaccine 2 Booster dose of inactivated polio vaccine 3 Two doses of diphtheria, tetanus, and pertussis vaccine 4 First booster dose of diphtheria, tetanus, and pertussis vaccine

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While a 3-month-old infant is at the well-baby clinic for a checkup, the parents express concern that their baby still has a soft spot on the top of the head. The nurse informs the parents that their infant's anterior fontanel will close around: 1 6 to 8 months of age 2 9 to 12 months of age 3 13 to 18 months of age 4 19 to 36 months of ag

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An infant who weighed 7.5 lb at birth now weighs 15 lb at 1 year. The nurse concludes that this infant's weight gain: 1 Suggests possible maternal neglect 2 Reflects the expected growth curve 3 Signifies an inadequate weight gain 4 Indicates insufficient dietary protein

3 The infant's weight signifies inadequate weight gain, according to the weight charts of the National Center for Health Statistics. An infant's total weight at the end of the first year should be three times the birth weight. Suggesting maternal neglect is a judgmental reaction; more evidence is needed to come to this conclusion. There are not enough data to determine whether the infant has an insufficient intake of dietary protein.

A nurse at the well-child clinic determines a 1-year-old infant's length to be below what is expected. The current height is 28 inches, and the birth length was 20 inches. What should this infant's current length be? Record your answer using a whole number. ___ inches

30 This infant is 2 inches shorter than expected. At 1 year of age an infant should have increased the birth length by 50%; 50% of 20 inches is 10 inches; 10 inches added to the birth length of 20 inches equals 30 inches.

A 1-month-old infant with a ventricular septal defect (VSD) is examined in the cardiology clinic. What sign related to this disorder does the nurse expect to find when assessing this infant? 1 Bradycardia at rest 2 Activity-related cyanosis 3 Bounding peripheral pulses 4 Murmur at the left sternal border

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A 1-year-old infant is in the pediatric unit for management of AIDS. One of the medications that has been prescribed for the child is zidovudine (Retrovir). What clinical finding indicates to the nurse that the infant is experiencing life-threatening zidovudine toxicity? 1 Fatigue and lethargy 2 increased urine output 3 Progressive weight loss 4 Bruises on the limbs and trunk

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An infant who has had diarrhea for 3 days is admitted in a lethargic state and is found to be breathing rapidly. The parent states that the baby has been taking formula, although not as much as usual, and cannot understand the sudden change. What explanation should the nurse give the parent? 1 Cellular metabolism is unstable in young children. 2 The proportion of water in the body is less than that in adults. 3 Renal function is immature in children until they reach school age. 4 The extracellular fluid requirement per unit of body weight is greater than in adults

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Which observation during a developmental appraisal of a 6-month-old infant is most important to the nurse in light of a diagnosis of hydrocephalus? 1. head lag 2. babinski 3. inability to sit unsupported

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A nurse is caring for an infant who just underwent surgery for a cleft lip. In which position should the nurse place the infant? 1 Prone 2 Low Fowler 3 Left side-lying 4 caregiver's shoulder

2 Low Fowler or supine position prevents the incision from coming into contact with the mattress and is the preferred position for infants. Lying prone causes frictional contact with the mattress and can result in stress on the suture line. Both the left and right side-lying positions may cause stress on the suture line. Although holding the infant is recommended, positioning the infant on the caregiver's shoulder may cause friction on the suture line if the baby's head should drop forward.