Infant

An infant is brought to the clinic with a possible diagnosis of Wilms' tumor. When obtaining the health history, which question should the nurse consider a priority to ask the parent? "Did your baby have a reddish jelly-like bowel movement?" "Does your baby have a pulsating anterior fontanel?" "Does your baby have projectile vomiting after feeding?" "Did the healthcare provider find a mass in the abdominal area?"

"Did the healthcare provider find a mass in the abdominal area?" The most common sign of Wilms' tumor is a painless, palpable abdominal mass, sometimes accompanied by an increase in abdominal girth. Projectile vomiting after a feeding is found with pyloric stenosis. A reddish, jelly-like bowel movement referred to as "currant jelly" is seen in intussusception. A pulsating anterior fontanel is a normal finding.

The nurse is caring for an infant admitted with a severe respiratory infection. The nurse is explaining the risk of airway obstruction and the need for frequent respiratory assessments to the parents. Which of the following statements by the nurse is most appropriate regarding the risk of airway obstruction? "The rapid respiratory rate of an infant makes it more likely that the infant will experience airway obstruction." "The thin chest wall of an infant significantly increases the risk of airway obstruction." "The infant's larger tongue and smaller oral cavity increase the risk of airway obstruction." "Infants have a flattened rib wall during inspiration, which increases the risk of airway obstruction."

"The infant's larger tongue and smaller oral cavity increase the risk of airway obstruction." The relatively larger tongue and smaller oral cavity of a child means that the tongue is more likely to obstruct the airway and increase resistance to airflow than in an adult. A flattened rib wall, thin chest wall, and rapid respiratory rate are all accurate descriptions of a pediatric population but they do not potentially put the child at the greatest risk for airway obstruction.

After the nurse instructs the parents of a 5-month-old infant about the purpose of the Denver Developmental Screening Test (DDST), which statement by the parents about what the test measures would indicate that the teaching was effective? "This test measures a child's potential for future development." "This test measures a child's IQ." "This test measures a child's social and physical abilities." "This test measures a child's emotional development."

"This test measures a child's social and physical abilities." The Denver Developmental Screening Test (DDST) measures a child's social, language, and fine and gross motor skills by testing abilities that usually occur at a given age.The DDST is not designed to measure intelligence or emotional development nor does it necessarily predict future development.

The nurse is preparing to discharge a 9-month-old infant recovering from gastroenteritis and dehydration and teaching a parent regarding the infant's dietary and fluid requirements. Which of the following statements made by the parent indicates that further instruction is required? "We will monitor the baby for any signs of dehydration." "We will bring my child back to the primary care provider if the diarrhea begins." "We may need to consider giving the child a lactose-free formula if diarrhea continues." "We can go ahead and begin to the feed the baby whatever they want to eat and drink."

"We can go ahead and begin to the feed the baby whatever they want to eat and drink." The baby will not be able to indicate when hungry or thirsty initially since appetite may be inhibited after the dehydration and could lead to further dehydration. It is appropriate for the parents to bring the child back if further diarrhea occurs. A lactose-free formula may be considered if the diarrhea continues and is unrelated to the gastroenteritis.

While assessing a 2-month-old infant's airway, the nurse finds that the infant is not breathing. After two unsuccessful attempts to establish an airway, which should the nurse do next? Administer five chest thrusts. Attempt to establish an airway a third time. Attempt to ventilate with a handheld resuscitation bag. Administer five back blows.

Administer five back blows. The nurse should clear the airway with back blows first followed by chest thrusts. After two attempts to establish an airway, the nurse can assume the airway is blocked. The nurse cannot attempt to ventilate the infant with a handheld resuscitation bag until the airway is patent.

Before a routine checkup, an 8-month-old infant sits contentedly on the parent's lap, chewing on a toy. When preparing to examine this infant, what should the nurse plan to do first? Measure the head circumference. Auscultate the heart and lungs. Weigh the child. Elicit the pupillary reaction.

Auscultate the heart and lungs. The nurse should first auscultate the heart and lungs because this assessment rarely distresses an infant. Placing a tape measure on the infant's head, shining a light in the eyes, or undressing the infant before weighing may cause distress, making the rest of the examination more difficult.

The father of a neonate observes that the neonate's big toe dorsiflexes and the other toes fan when the nurse gently strokes the sole of the foot. How should the nurse should interpret this finding? Babinski's sign stepping reflex Galant reflex plantar grasp reflex

Babinski's sign A positive Babinski's sign involves dorsiflexion of the big toe and fanning of the other toes. Although normal in infants, this response is abnormal after about age 1 year or when walking begins.The stepping reflex occurs when an infant is held as though weight bearing with the feet on a surface and the infant steps along, raising one foot at a time.A plantar grasp reflex is characterized by flexion of the toes when a finger is placed against the base of the toes.A normal Galant reflex is initiated by stroking an infant's back alongside the spine. The hips should move toward the stimulated side.

Which instruction should the nurse expect to include in the discharge teaching plan for the parent of an infant who has had an inguinal herniorrhaphy? Change diapers as soon as they become soiled. Keep the incision covered with a sterile dressing. Apply an abdominal binder. Restrain the infant's hands.

Change diapers as soon as they become soiled. Changing a diaper as soon as it becomes soiled helps prevent wound infection, the most common complication after inguinal hernia repair in an infant secondary to possible wound contamination with urine and stool. Because the surgical wound is unlikely to separate, an abdominal binder is unnecessary. The incision may or may not be covered with a dressing. If a dressing is not used, the health care provider (HCP may apply a topical spray to protect the wound. Restraining the infant's hands is unnecessary if the diaper is applied snugly. The infant would be unable to get the hands into the diaper close to the surgical site.

Which action should the nurse take in the immediate period following application of a plaster cast to correct a child's congenital clubfoot? Handle the cast with the fingertips. Change the child's position at least every 2 hours. Dry the cast rapidly with a hair dryer. Coat the cast with a clear acrylic spray finish.

Change the child's position at least every 2 hours. Complete drying of a plaster cast takes several hours. Thus, turning the child with a newly applied cast at least every 2 hours helps the cast to dry uniformly.The cast must not be coated with any substance that would inhibit moisture evaporation from the plaster.Dryers are not used to dry the cast because they dry the cast on the surface but not underneath. Furthermore, heat may be conducted to the tissues through the wet cast, causing burns.The drying cast must be handled with the palms only to prevent finger indentations that could cause pressure areas.

What discharge instructions should the nurse give the parents of an infant with a temporary colostomy? Give the infant plenty of liquids to drink. Allow the diaper to absorb the colostomy drainage. Expect the stoma to become dusky red within 2 weeks. Flush the stoma with tap water at least once a day.

Give the infant plenty of liquids to drink. Because of decreased fluid reabsorption from the colon, the child with a colostomy benefits from a liberal fluid intake. Infants also dehydrate more quickly than adults do because of immature kidneys, larger body surface area, and more fluid in the extracellular spaces. Therefore, the parents need instructions about giving the infant plenty of liquids to drink.Tap water flushes of the stoma are contraindicated in infants because of the risk for absorption of free water and the potential for fluid overload.An appliance should be fitted over the stoma for stool collection to help prevent skin breakdown.The stoma should always be reddish-pink and moist. A dusky-red stoma may indicate impaired circulation to the area.

Three weeks after an infant receives a spica cast, the mother calls the nurse because the infant's toes are swollen and cool to the touch. What should the nurse instruct the mother to do? Have the child fitted for a larger cast. Inspect the area for an infection. Place the child's legs in a lowered position. Put more cotton wadding to line the casting.

Have the child fitted for a larger cast. Infants grow rapidly and may require application of a larger cast. A cast adequate for an infant after surgery may be outgrown in less than 1 month. The cast becomes too tight, impairing circulation evidenced by toe swelling and coolness to touch.The mother should keep the child's feet in a recumbent position. When feet are dependent in a cast, decreased venous return may occur. Reduced venous return along with decreased feet and leg movement subsequently leads to edema, which resolves when the feet are returned to a recumbent position.The cotton wadding used to line the cast does not shrink over time.If the child had surgery, the chances of infection are minimal after a 3- to 4-week period. In addition, other symptoms of infection, such as fever and possibly a hot spot on the cast, would be present.

Which serum electrolytes findings should the nurse expect to find in an infant with persistent vomiting? K+, 3.2; Cl-, 92; Na+, 120 K+, 3.4; Cl-, 120; Na+, 140 K+, 3.5; Cl-, 90; Na+, 145 K+, 5.5; Cl-, 110; Na+, 130

K+, 3.2; Cl-, 92; Na+, 120 Chloride and sodium function together to maintain fluid and electrolyte balance. With vomiting, sodium chloride and water are lost in gastric fluid. As dehydration occurs, potassium moves into the extracellular fluid. For these reasons, persistent vomiting can lead to hypokalemia, hypochloremia, and hyponatremia.The normal potassium level is 3.5 to 5.5, the normal chloride level is 98 to 106, and the normal sodium level is 135 to 145. The values of 3.2, 92, and 120, respectively, are consistent with persistent vomiting.Each of the other options includes at least two serum electrolyte levels that are normal or high. These are not consistent with persistent vomiting.

An infant is scheduled for surgery to repair an inguinal hernia. The parent asks the nurse why the infant has been scheduled for surgery when the hernia has been asymptomatic. Which statement offers the best explanation of why the surgical repair should be done at this time? Less danger and fewer complications result when surgery is an elective procedure. An infant is better able to tolerate the physical stress of surgery than an older child is. Doing surgery near the genital organs is preferred before a child becomes conscious of sexual identity. The experience of surgery is less frightening for the younger child.

Less danger and fewer complications result when surgery is an elective procedure. Inguinal hernia repair is ordinarily done promptly after diagnosis in healthy infants and children. Delaying surgery may result in a possible partial obstruction due to a loop of bowel protruding into the inguinal canal. Serious progression with complete obstruction and perhaps strangulation of the bowel requires emergency surgery to prevent gangrene, which could be fatal.Infants do not have a physiologic or psychological advantage in surgery compared with older children.Infants, like other children and adults, experience stress and fear when having surgery.Although performing surgery around the genitals before the preschool years is recommended, the best reason for performing this surgery immediately would be to avoid having to perform emergency surgery later.

The nurse is teaching a health promotion class to new mothers about sudden infant death syndrome (SIDS). What information would be most important for the nurse to teach? Prevention includes placing the infant supine on a firm sleeping surface. SIDS usually occurs before the infant turns one year of age. SIDS is more common in infants who were born prematurely. Although there are associated risk factors, the cause is not known.

Prevention includes placing the infant supine on a firm sleeping surface. All the statements are true, but the most important information for new mothers would be related to steps they can take to reduce the risk for SIDS, such as using a firm sleeping surface and placing the infant on the back. Statistics about the age at which SIDS occurs or stating that the cause is not known may be included as basic background information, but this information does nothing to help the mothers prevent SIDS. Similarly, although premature birth is a risk factor, this information is less important than guidance that equips mothers to protect their infants.

Which instruction would be most appropriate for the nurse to include in the teaching plan for the mother of a 1-year-old child who is to receive iron therapy with ferrous sulfate drops? Put the drops in the child's mouth, then follow with juice. Mix the drops with a cup of milk. Dilute the drops with water and put them in the child's mouth. Put the drops in the child's mouth, then follow with milk.

Put the drops in the child's mouth, then follow with juice. Absorption of iron is enhanced in an acid environment. Thus, iron drops are better absorbed when mixed with fruit juice or followed by fruit juice.Medications should not be mixed in a cup or bottle of fluids. If the child does not drink the entire cup or bottle, it is difficult to determine how much of the medication the child actually received. Also, even though the child may be learning to use a cup, it may spill, again making it difficult to determine the amount of medication that the child has received. In addition, milk tends to decrease iron absorption.Putting the drops in the child's mouth is appropriate. However, following administration with milk should be avoided because milk decreases iron absorption.Medications should not be diluted with water. If the child does not swallow the entire dose, it is difficult to determine how much of the medication the child actually received.

The nurse is caring for an infant diagnosed with nonorganic failure to thrive. Which action should be included in the plan of care for the infant? Weighing the unclothed infant at the same time every day. Reporting the caregiver to social services for suspected abuse. Requiring the caregiver to attend a community support group prior to discharge. Suggesting to the infant's caregiver to continue to try to feed the infant even when the infant is crying.

Weighing the unclothed infant at the same time every day. Daily weights are an appropriate intervention for an infant with failure to thrive. It would be inappropriate for the nurse to encourage the caregiver to continue to try to feed the infant when crying because the infant may develop further aversion to eating. It is also inappropriate to assume that abuse has taken place; there is no information in the stem to suggest this. The caregiver would benefit from a community support group; however, the nurse cannot require the caregiver to attend a community support group prior to discharge.

Eight hours ago, an infant with Hirschsprung's disease had surgery to create a colostomy. Which finding should alert the nurse to notify the health care provider (HCP) immediately? bright red stoma a 3-cm increase in abdominal circumference periods of occasional fussiness absence of bowel sounds since surgery

a 3-cm increase in abdominal circumference Abdominal circumference is measured to monitor for abdominal distention. An increase of 3 cm in 8 hours would require notification of the HCP; it would indicate a substantial degree of abdominal distention, possibly from fluid or gas accumulation. Normally, after surgery, an infant experiences occasional periods of fussiness. However, as long as the infant is able to be quiet by himself or with the aid of a pacifier, the HCP does not need to be contacted. Absence of bowel sounds would be expected after surgery because of the effects of anesthesia. It takes approximately 48 hours for gastric motility to resume. New stomas are typically bright red or pink.

The nurse evaluates the understanding of parents of a 12-month-old with iron-deficiency anemia of how to administer iron supplements. Which action(s) would indicate the parents are correctly administering the iron supplements? Select all that apply. administering iron supplements in combination with fruit juice decreasing the dietary intake of foods fortified with iron. verbalizing the need to report dark stools scheduling iron supplements with meals brushing the child's teeth after administering the iron supplements

administering iron supplements in combination with fruit juice brushing the child's teeth after administering the iron supplements Parent teaching concerning a child with iron-deficiency anemia should include directions about giving iron combined with fruit juice, in divided doses, between meals, and with a dropper for a 12-month-old or through a straw for older toddlers. Iron stains teeth, so brushing the teeth and administering liquid iron through a dropper or straw are necessary to prevent staining the teeth. Iron should not be given with milk, antacids, or tea and should be administered on an empty stomach. Iron will cause the stool to become black or green, which is normal and does not need to be reported. However, light-colored stools indicate the iron is not being absorbed and should be reported.

After receiving a report, the nurse is making out assignments. Which client would be appropriate to assign to unlicensed assistive personnel? a 6-year-old with a femur fracture and a fever a 13-year-old adolescent with fluctuating vital signs and a new central line an 8-month-old with pneumonia who will be discharged today a 7-year-old transferred from the cardiac intensive care unit

an 8-month-old with pneumonia who will be discharged today The most appropriate client to assign to unlicensed assistive personnel would be the infant who is stable. Registered nurses have the responsibility for assessment, evaluation, and making nursing judgments. Unlicensed assistive personnel can care for a client with pneumonia who will be discharged because this child is stable.The child with a fractured femur, the adolescent with fluctuating vital signs and a new central line, and the infant who recently underwent surgery should be cared for by a registered nurse who can make appropriate judgments and perform required procedures.

In developing a security plan for a pediatric unit, a nurse must consider which factors? Select all that apply. available resources to obtain and maintain the security plan the facility's physical layout identification of neonates, infants, toddlers, children, and adolescents at all times methods for educating all staff regarding the security plan the climate in which the hospital is located

available resources to obtain and maintain the security plan the facility's physical layout identification of neonates, infants, toddlers, children, and adolescents at all times methods for educating all staff regarding the security plan When developing a security plan for a pediatric unit, the nurse should consider the identification of neonates, infants, toddlers, children, and adolescents; the facility's physical layout; available resources; and methods for educating staff. The nurse does not need to consider the climate in which the hospital is located.

A 9-month-old, well-nourished boy who lives with his extensive extended family tests positive for tuberculosis. What is a risk factor for tuberculosis in this child? being an infant having a mother who did not receive prenatal care until the second trimester of her pregnancy being in the 95th percentile for height and weight being male

being an infant Infants are more susceptible to tuberculosis because of a diminished resistance to infection due to an immature immune system.In later childhood and adolescence, morbidity and mortality are higher in females than males.A higher-than-average weight and height would indicate that the child has had good nutrition. Poor nutrition is a risk factor for tuberculosis.Prenatal care is unrelated to tuberculosis.

An infant has just had surgery to repair a cleft lip. Which nursing intervention is most important during the immediate postoperative period? laying the infant on the abdomen to help drain fluids from the mouth giving the infant a pacifier to suck for comfort cleaning the suture line carefully with a sterile solution after every feeding allowing the infant to cry to promote lung reexpansion

cleaning the suture line carefully with a sterile solution after every feeding To avoid an infection that could adversely affect the cosmetic outcome of the repair, the suture line must be cleaned very gently with a sterile solution after each feeding. Laying an infant on the abdomen after a cleft lip repair isn't appropriate because doing so will put pressure on the suture line, causing damage. The infant can be positioned on the side to drain saliva without affecting the suture line. Crying puts tension on the suture line and should be avoided by anticipating the baby's needs, such as holding and cuddling. Hard objects such as pacifiers should be kept away from the suture line because they can cause damage.

The nurse develops a teaching plan for the parents of a child with trisomy 21. The nurse focuses on activities to increase which factor for the parents? confidence in their ability to care for their child responsibility for their child's welfare affection for their child understanding of their child's disability

confidence in their ability to care for their child When the nurse is teaching the parents of a child with trisomy 21, also known as Down syndrome, activities should focus on increasing the parents' confidence in their ability to care for their child. The parents must continue to work daily with their child. Most parents feel affection and a sense of responsibility for their child regardless of the child's limitations. Parents usually understand the child's disability on the cognitive level but have difficulty accepting it on the emotional level. As the parents' confidence in their caring abilities increases, their understanding of the child's disability also increases on all levels.

While attending a support group, the parents of a child with hemophilia become concerned because they heard stories about how many children with hemophilia have died from acquired immunodeficiency syndrome (AIDS). They ask the nurse how these children got the AIDS virus. The nurse bases the response on which as the most likely route of transmission of AIDS to these children? use of a contaminated needle to obtain a blood sample for type and crossmatching casual contact with a child testing positive for human immunodeficiency virus exposure in the waiting room to children with AIDS attending the same hematology clinic contamination of the factor VIII replacement received during bleeding episodes

contamination of the factor VIII replacement received during bleeding episodes The acquired immune deficiency syndrome (AIDS) virus is spread by direct contact with blood or blood products and by sexual contact. Children with hemophilia were at risk for AIDS in the 1980s because the factor VIII concentrate infusions were made from pooled plasma. However, factor VIII is now a recombinant synthesized factor product, which virtually eliminates the risk of contacting HIV with an infusion.There is no evidence that casual contact between infected and uninfected people transmits the human immunodeficiency virus (HIV). Exposure to others in a waiting room is considered casual contact.All venipunctures for blood specimens in hospitals and clinics are performed with sterile disposable needles. Because the needles are sterile, they cannot be a source of HIV transmission.

A client brings her 6-month-old infant in for a well-baby visit. During the exam, the nurse is unable to elicit the Moro reflex. Which is the appropriate action by the nurse? contacting the physician with the finding waiting 5 minutes then attempting to elicit the reflex again explaining that this reflex disappears around 6-8 weeks explaining to the client that this reflex disappears around 3-4 months

explaining to the client that this reflex disappears around 3-4 months The Moro reflex disappears around 3-4 months of age; therefore, it is considered a normal finding for it not to be elicited in a 6-month-old infant. The nurse should explain to the parent that the reflex disappears around 3-4 months. There is no need to attempt to elicit the reflex again or to contact the physician with the finding.

The nurses teaches the parents of an infant how to perform back slaps to dislodge a foreign body. What should the nurse tell the parents to use to deliver the blows? heel of the hand palm of the hand fingertips entire hand

heel of the hand Back slaps are delivered rapidly and forcefully with the heel of the hand between the infant's shoulder blades. Slowly delivered back slaps are less likely to dislodge the object. Using the heel of the hand allows more force to be applied than when using the palm or the whole hand, increasing the likelihood of loosening the object. The fingertips would be used to deliver chest compressions to an infant younger than 1 year of age.

A nurse is caring for a family whose infant has anencephaly. The most appropriate nursing intervention is to: prepare the family for the extensive surgical procedures the infant will require. provide emotional support so the family can adjust to the birth of an infant with health problems. help the family prepare for the infant's imminent death. implement measures to facilitate the attachment process.

help the family prepare for the infant's imminent death. Anencephaly is incompatible with life. The nurse should support family members as they prepare for the infant's imminent death. Facilitating the attachment process, helping the family to adjust to the infant's problems, and preparing the family for extensive surgical procedures are inappropriate because the infant can't survive.

Which activity by the mother offers the most support to the child during the first few days after surgery to repair a cleft lip? reading some of the child's favorite stories holding and cuddling the child staying at the bedside and holding the child's hand helping the child play with some toys

holding and cuddling the child The mother should be encouraged to hold and cuddle her child to provide needed emotional support. Such activities as helping the child play with toys, reading stories, and staying with the child would not be contraindicated, but these activities do not offer as much emotional support as holding and cuddling.

A 9-month-old infant is admitted with diarrhea and dehydration. The nurse plans to assess the child's vital signs frequently. Which other action provides important assessment information? inspecting the infant's posterior fontanel obtaining a stool specimen for analysis obtaining a urine specimen for analysis measuring the infant's weight

measuring the infant's weight Frequent weight measurement provides the most important information about fluid balance and the infant's response to fluid replacement. Although stool or urine analysis may provide some information, the results typically aren't available immediately, making the tests less useful than measuring weight. The posterior fontanel usually closes from ages 6 to 8 weeks and therefore doesn't reflect fluid balance in a 9-month-old infant.

Which night clothes would the nurse recommend for an infant with atopic dermatitis? one-piece cotton pajamas with long sleeves a diaper and short-sleeved shirt two-piece flannel pajamas with short sleeves a woolen sleeper with feet and mittens

one-piece cotton pajamas with long sleeves Atopic dermatitis results in pruritus. The infant's skin should be covered as completely as possible to keep him from scratching himself. Cotton is the preferred material because it allows the skin to breathe and moisture to evaporate.A short-sleeved shirt would be inappropriate because the infant could scratch the uncovered arms, exacerbating the condition.Flannel may be too warm, causing the child to perspire, which will aggravate the condition.Because atopic dermatitis is commonly associated with allergies, wool garments should be avoided.

When fluids by mouth are appropriate for the infant after surgery to correct intussusception, the nurse most likely would initiate which type of feeding? oral electrolyte solution full-strength formula half-strength formula cereal-thickened formula

oral electrolyte solution When a child is ready to take fluids by mouth postoperatively, clear liquids are given initially. If clear liquids are tolerated, the concentration and amount of oral feedings are gradually increased. This means advancing to half-strength and then to full-strength formula while increasing the amount given with each feeding.

An infant, age 6 weeks, is brought to the clinic for a well-baby visit. Which position is best for the nurse to assess the fontanel? placed in prone position placed in supine position placed in the left lateral position held in upright position

held in upright position For the most accurate results, the nurse should seat the infant upright to assess the fontanels and should perform this assessment when the infant is quiet. Pressure from postural changes or intense crying may cause the fontanels to bulge or seem abnormally tense. When the infant is in a recumbent position, the fontanel is less flat than it is normally, creating the false impression that intracranial pressure is increased.

The health care provider prescribes an intravenous infusion of 5% dextrose in 0.45% saline to be infused at 2 mL/kg per hour in an infant who weighs 9 lb (4.1 kg). How many milliliters per hour of the solution should the nurse infuse? Round to one decimal place. _____ mL per hour.

8.2 4.1 kg × 2 mL/kg = 8.2 mL/hour

The nurse teaches a parent about feeding an infant with colic. The nurse determines that the parent has understood the teaching when the nurse observes the parent doing which action? placing the infant prone after the feeding holding the infant in their lap to burp holding the infant prone while feeding burping the infant during and after the feeding

burping the infant during and after the feeding Infants with colic should be burped frequently during and after the feeding. Much of the discomfort of colic appears to be associated with the presence of air in the stomach and the intestines. Frequent burping helps to relieve the air. Infants with colic should be held fairly upright while being fed, to help air rise. The preferred position for burping the infant with colic is to hold the infant at the parent's shoulder so that the infant's abdomen lies on the shoulder. This position causes more pressure to be exerted on the infant's abdomen, leading to a more forceful burp. The child should be placed in an infant seat after feedings.

When performing a physical examination on a neonate, the nurse notes low-set ears. What action should the nurse perform next? Order an ultrasound of the head to determine if the brain is normal. Note the findings in the medical record. Call the pediatrician for an immediate evaluation of the infant. Assess the neonate to determine if other apparent abnormalities are present.

Assess the neonate to determine if other apparent abnormalities are present. Although low-set ears are an abnormal finding, the presence of this abnormality by itself isn't cause for immediate concern. The nurse should continue to assess the neonate to determine if other abnormalities are present. It's appropriate to note the abnormality in the medical record; however, it's even more important to continue the assessment. It's outside the scope of nursing practice to order a diagnostic test, such as an ultrasound, and there's no indication for this test.

A nurse is assessing an infant for signs of increased intracranial pressure (ICP). What is the earliest sign of increased ICP in an infant? vomiting vital sign changes papilledema irritability

irritability An infant with increased ICP is commonly fussy, irritable, and restless at first as a result of a headache cause by the ICP. Vomiting occurs later. Papilledema is a late sign of increased ICP that may not be evident. Changes in vital signs occur later; pressure on the brainstem slows pulse and respiration.

A nurse is teaching the parents of an infant with clubfeet about cast care. Which statement by the parent indicates the need for further teaching? "I know I will have to be careful when changing the diapers." "I hope this cast will cure the feet in the next several weeks." "I will have to be careful how I hold the baby." "Immunizations will have to be delayed until the casts come off."

"Immunizations will have to be delayed until the casts come off." The parent's statement about delaying immunizations indicates the need for further teaching. Immunizations can be administered in the thighs because the casts cover only the lower legs and feet. The other responses are correct statements, indicating effective teaching.

The nurse creates a teaching plan for the family of an older infant who has had a spica cast applied for developmental dysplasia of the hip. Which information should the nurse include when describing the abduction stabilizer bar? It adds strength to the cast. It can be adjusted to a position of comfort. It is used to lift the child. It is necessary to turn the child.

It adds strength to the cast. The abduction bar is incorporated into the cast to increase the cast's strength and maintain the legs in alignment. The bar cannot be removed or adjusted unless the cast is removed, and a new cast is applied. The bar should never be used to lift or turn the client because doing so may weaken the cast.

The nurse is inserting a nasogastric tube in an infant to administer feedings. In the figure below, indicate the location for the correct placement of the distal end of the tube.

The nasogastric tube should reside in the stomach. The site placement can be verified by inserting 3 to 5 mL of air in the tube and auscultating the infant'sinfant's abdomen for the sound of air. The nurse should then aspirate the injected air and a small amount of stomach contents and then test the contents for acidity.

An infant, age 3 months, undergoes surgical repair of a cleft lip. After surgery, the nurse should use which equipment to feed the infant? single-hole nipple plastic spoon paper straw rubber dropper

rubber dropper An infant with a surgically repaired cleft lip must be fed with a rubber dropper or Breck feeder to prevent sucking or suture line trauma. A single-hole nipple, a plastic spoon, and a paper straw wouldn't prevent these actions.

When teaching the mother of an infant diagnosed with congenital hypothyroidism about daily oral levothyroxine sodium therapy, which manifestation should the nurse include as possibly indicating an overdose? anorexia sweating constipation sleepiness

sweating Sweating, insomnia, rapid pulse, dyspnea, irritability, fever, and weight loss are all signs indicating levothyroxine overdose.Diminished or absent appetite (anorexia), constipation, and fatigue and sleepiness would suggest thyroid insufficiency.

A nurse walks into the room just as a 10-month-old infant places an object in his mouth and starts to choke. After opening the infant's mouth, what should the nurse do next to clear the airway? Use blind finger sweeps. Deliver back slaps and chest thrusts. Apply four subdiaphragmatic abdominal thrusts. Attempt to visualize the object.

Deliver back slaps and chest thrusts. The nurse should use mechanical force—back slaps and chest thrusts—when attempting to dislodge the object. Blind finger sweeps are not appropriate in infants and children because the foreign body may be pushed back into the airway. Subdiaphragmatic abdominal thrusts are not used for infants age 1 year or younger because of the risk for injury to abdominal organs. If the object is not visible when the child's mouth is open, time is wasted in looking for it. Action is required to dislodge the object as quickly as possible.

An infant underwent surgery to remove a myelomeningocele. The infant has bulging fontanels. Which is the nurse's best action? Notify the healthcare provider. Teach the parent about procedure. Reposition the infant. Calm the infant.

Notify the healthcare provider. Bulging fontanels in an infant may indicated increased intracranial pressure, a possible postoperative complication. Calming the infant, teaching the parent, and repositioning the infant will not address the underlying problem of increased intracranial pressure within the skull. Calling the healthcare provider is indicated.

The nurse is assessing the primitive reflexes of a 1-month-old infant. Of the reflexes shown in the photos, which one would the nurse expect to remain the longest?

Option B shows the plantar grasp reflex which is noted to disappear by 8 months. Of the options, this reflex will remain the longest. Option A is the palmer grasp which will disappear around 3 months. Option C is the Moro reflex which will disappear around 4 months. Option D is the tonic neck reflex which will disappear around 3 to 4 months.

The nurse is performing an assessment in the nursery on an infant with a developmental hip dysplasia. Which findings should the nurse anticipate? increased hip abduction Ortolani's sign symmetrical thigh and gluteal folds femoral lengthening

Ortolani's sign Assessment in a child with a congenital hip dislocation typically reveals Ortolani's sign, asymmetrical thigh and gluteal folds, limited hip abduction, femoral shortening, and Trendelenburg's sign.

A dehydrated infant is receiving IV therapy. The parent tells the nurse about wanting to hold the infant but being afraid this might cause the IV line to become dislodged. How should the nurse respond? Place a restraint on the arm with the IV site so it cannot move or become dislodged. Encourage the parent to interact with the infant while lying in the bed. Temporarily disconnect the IV line so the parent can hold the child comfortably. Provide a comfortable chair for the parent to hold the infant while connected to the IV.

Provide a comfortable chair for the parent to hold the infant while connected to the IV. Infant bonding is very important, and the need increases when the child is ill. The parent should be provided with a comfortable chair with support to help hold the infant. The IV pump needs to be close to the chair with enough tubing to allow for movement. Placing a restraint over the IV site requires a prescription from the health care provider and is not necessary. The IV site can be protected with blankets or clothing. The nurse should encourage the parent to participate in the child's care whenever possible, not just during IV therapy. The IV should not be disconnected for bonding time. IV fluids should remain continuously at a rate prescribed by the health care provider.

The nurse is assessing the development of a 7-month-old. The child should be able to perform which skill? Play pat-a-cake. Sit without support. Say two words. Wave bye-bye.

Sit without support. The majority of infants (90%) can sit without support by 7 months of age.Approximately 75% of infants at 10 months of age are able to play pat-a-cake.The ability to say two words occurs in 90% of children by age 16 months.A child typically can wave bye-bye at about 14 months of age.

A nurse has received report on her clients and notices that they're of varying ages. To prepare for the shift, the nurse reviews Erik Erikson's five stages of psychosocial development. Place the stages in chronological order from infancy to adolescence. Use all options.

Trust versus mistrust Autonomy versus shame and doubt Initiative versus guilt Industry versus inferiority Identity versus role confusion During the first stage of Erikson's five stages of psychosocial development, trust versus mistrust (birth to age 1), the child develops trust as the primary caregiver meets his needs. In the second stage, autonomy versus shame and doubt (ages 1 to 3), the child gains control of body functions and becomes increasingly independent. In the third stage, initiative versus guilt (ages 3 to 6), the child develops a conscience and learns about the world through play. In the fourth stage, industry versus inferiority (ages 6 to 12), the child enjoys working on projects with others, follows rules, and forms social relationships. As body changes begin to take place, the child enters the fifth stage, identity versus role confusion (ages 12 to 19), and becomes preoccupied with looks, how others view him, meeting peer expectation, and establishing his own identity.

An infant is admitted to the hospital with dehydration secondary to viral gastroenteritis. Which room assignment is the most appropriate for this infant? a private room a semiprivate room with a 10-year-old child with a closed head injury a semiprivate room with a 4-year-old child with leukemia a semiprivate room with an 8-year-old child who has had an appendectomy

a private room Viral gastroenteritis may be communicable, and all of the other children are already at risk for infection. The infant should be placed in a private room.

The nurse is assessing children at risk for phenylketonuria (PKU). Which child is at greatest risk? a red-headed child who experiences frequent contact dermatitis African descent, dark-eyed child with asthma child with dark complexion who is overweight and has labile personalities blond, blue-eyed, fair-skinned child with eczema

blond, blue-eyed, fair-skinned child with eczema Infants with PKU are usually blond, blue-eyed, and fair, and often have eczema. The other physical assessment findings are not typically found in children with PKU.

The parent of a 6-month-old reports starting the child on 2% milk. What should the nurse ask the parent first? "Do you think your baby will be fine with this milk?" "Is it possible for you to switch your baby to whole milk?" "Can you tell me more about the reason you switched your baby to 2% milk?" "You cannot switch to 2% milk right now. Did your pediatrician tell you to do this?"

"Can you tell me more about the reason you switched your baby to 2% milk?" The American Academy of Pediatrics and Canadian Pediatric Society recommend that infants remain on iron-fortified formula or breast milk until 1 year of age. The nurse needs to first assess if the parent switched the baby prematurely because of a lack of information or lack of resources. Then appropriate teaching or referrals may be determined. At 1 year of age, the infant may be switched to whole milk, which has a higher fat content than 2%. A higher fat content is needed for brain growth. Demanding clients change behaviors without addressing the cause is unlikely to produce desired results.

The mother of an infant with iron deficiency anemia asks the nurse what she could have done to prevent the anemia. The nurse should teach the mother that it is helpful to introduce solid foods into the infant's diet at which age? 6 months 8 months 10 months 3 months

6 months Solids should be introduced at 6 months. Full-term infants use up their prenatal iron stores within 4 to 6 months after birth. Milk contains insufficient iron.

A parent brings a 7-month-old infant to the well-baby clinic for a check-up. The parent feeds the infant formula whenever the infant is hungry but is concerned that the infant is overweight. What instructions should the nurse give the parent? Bring a 3-day record of the infant's intake back for further evaluation. Use skim milk because it is high in protein and lower in calories. Decrease the amount of formula feedings to 16 oz (480 mL) daily and supplement with juice and water. Give the infant 2% milk formula, and add vitamins.

Bring a 3-day record of the infant's intake back for further evaluation. A 3-day diet history is the best way to accurately assess the child's intake. Children under age 1 year should not drink cow's milk because of the risk for allergy. Children over age 1 year should drink whole milk because skim milk and 2% milk do not contain all the essential fatty acids needed by young children. It is unknown at this time how much formula the child is actually taking, but an infant should not have more than 6 oz (177.4 mL) of juice per day, and additional water is usually not necessary. If an infant is taking no more than 32 oz (946 mL) of formula per day and is eating some baby food and cereal, additional fluids and frequent feeding should not be necessary.

Client is an 11-month-old infant diagnosed with congenital ventricular septal defect presenting to the outpatient clinic for follow-up. The healthcare provider has reviewed recent testing and assessed the infant identifying that the ventricular septum has not closed. Which manifestations should the nurse monitor? Select all that apply. Hepatomegaly Cyanosis Failure to thrive Bradycardia Rapid weight gain Forceful apical pulse Bradypnea Pallor

Failure to thrive Hepatomegaly Cyanosis Pallor Forceful apical pulse The nurse will need to know the manifestations of ventricular septal defect to ensure early identification of potentially life-threatening events. Failure to thrive and hepatomegaly are manifestations of ventricular septal defect. Cyanosis and pallor are also manifestations of ventricular septal defect due to blood shunting from the left to the right ventricle. Forceful apical pulse may also occur due to heart pumping forcefully in attempt to adequately oxygenate the blood. Tachycardia, not bradycardia, is a manifestation of ventricular septal defect due to the heart pumping at a faster rate to adequately oxygenate the blood. Slow weight gain is a manifestation of ventricular septal defect. Tachypnea is a manifestation of ventricular septal defect due to the need for additional oxygenation of the blood. Bradypnea is not a manifestation.

The parents of a 3-month-old infant have been told that their infant has died of sudden infant death syndrome. Which intervention is most important to include in the plan of care to assist the parents with their grieving process? Provide an opportunity for them to see the infant. Ask them if they would like to call their religious advisor. Reassure them that the infant's death was not their fault. Give them a package containing the infant's clothing.

Provide an opportunity for them to see the infant. The parents should be given the opportunity to say their final farewells to their infant. This last contact helps them focus on the reality of the infant's death.Although helpful, reassuring them that they are not at fault does not focus on the reality of death, which is most important at this time.The presence of their pastor may be helpful, but enabling them to see their child would be more important.For some parents, clothes may be too painful a reminder of their child's death, and they may not wish to take them home.

The parent of a 2-week-old infant brings the child to the clinic for a checkup. The parent expresses concern about the baby's breathing because the infant breathes quickly for a while and then breathes slowly. The nurse interprets this finding as an indication of what factor? a normal pattern in infants of this age the need for an apnea monitor a need for close monitoring for the mother the need for a chest radiograph

a normal pattern in infants of this age The infant is exhibiting periodic breathing, which is normal in infants of this age. The infant typically alternates short periods of rapid, louder respirations with periods of slower, quieter respirations.

When preparing to admit an infant diagnosed with diarrhea to the pediatric unit, the nurse should assign the infant to which room? a single negative pressure room a room with other infants younger than age 1 year a two-bed room with an infant with respiratory disease a private room

a private room To reduce the risk of infection transmission, an infant with diarrhea of undetermined origin should be placed in a private room until a causative organism can be identified. However a negative pressure room is not needed because airborne precautions are not required with diarrheal disease.

When performing a heel stick on a newborn, the nurse is unable to obtain an adequate sample. What should the nurse do? Perform venipuncture instead. Call the health care provider. Place a cold compress on the heel. Attempt the heel stick in a new location.

Attempt the heel stick in a new location. If unable to obtain an adequate sample from a heel stick, using a different site, placing foot in a dependent position, and warming the heel are recommended. If none of this works, then venipuncture can be done. There is no need to call the health care provider and a cold compress decreases blood flow to the area instead of increasing blood flow.

A parent calls the clinic to report their 9-month-old infant has had 5 soft to loose stools today, has a decreased appetite, but is alert and playing. Which advice is most appropriate for the nurse to give the parent? "Feed your infant clear liquids only." "Notify your infant's daycare of his illness." "Continue your infant's normal feedings." "Call back if your infant has 10 stools in 1 day."

"Continue your infant's normal feedings." It is not unusual for infants to have several bowel movements per day, with breast-fed infants usually having more than formula-fed ones. If an infant has mild diarrhea lasting only one day with no change in energy level, the mother should be advised to continue the normal diet and to call back if the diarrhea continues or if the infant shows signs of dehydration. The nurse should teach the parent the symptoms of dehydration, such as decreased urine output, reduced tear production, or listlessness. There is no need to give the infant clear liquids only. Notifying the daycare about the infant's illness is important if the parent will be leaving the infant in their care, but it doesn't take priority.

A 10-month-old child with recurrent otitis media is brought to the clinic for evaluation. What is most important for the nurse to ask the family about the baby's symptoms? "Can the baby combine two words when speaking?" "Have you noticed a lot of wax in the baby's ears?" "Do you give the baby a bottle to take to bed?" "Does water ever get into the baby's ears during shampooing?"

"Do you give the baby a bottle to take to bed?" In a young child, the eustachian tube is relatively short, wide, and horizontal, promoting drainage of secretions from the nasopharynx into the middle ear. Therefore, asking if the child takes a bottle to bed is appropriate because drinking while lying down may cause fluids to pool in the pharyngeal cavity, increasing the risk of otitis media. Asking if the parent noticed earwax, or cerumen, in the external ear canal is incorrect because wax doesn't promote the development of otitis media. During shampooing, water may become trapped in the external ear canal by large amounts of cerumen, possibly causing otitis external (external ear inflammation) as opposed to internal ear inflammation. Asking if the infant can combine two words is incorrect because a 10-month-old child isn't expected to do so.

A nurse is teaching a new mother how to prevent burns in the home. Which statement by the mother indicates more teaching is required? "I will not hold my infant while drinking coffee." "I will set my hot water heater to 49° C (120° F)." "I will keep loose appliance cords tied up on the counter." "I will heat my infant's formula in the microwave."

"I will heat my infant's formula in the microwave." Infant formula should never be heated in the microwave; the formula may heat at different temperatures and can burn the infant's mouth. Plastic bottle liners may also burst with the heat. Setting your hot water heater a couple of degrees cooler will help keep hot water in the house cooler (recommended since 1974 by the Consumer Product Safety Commission). Small children are at risk for scald injury from hot tap water due to their decreased reaction time, their curiosity, and the thermal sensitivity of their skin. Avoiding holding infants while drinking coffee can prevent possible spills onto children. Keeping cords tied up on the counter prevents children from pulling on dangling cords and spilling hot liquids over themselves.

The mother of an infant with flat feet asks the nurse what she can do about the problem. Which response from the nurse is the most appropriate? "Corrective shoes will strengthen the arches of the feet." "Nightly exercises will help make the arches supple." "Flat feet cause other orthopedic problems in infants." "Infants have a fat pad below the arch, making it look like flat feet when they are not." SUBMIT ANSWER

"Infants have a fat pad below the arch, making it look like flat feet when they are not." Infants have a fat pad below the arch, giving the appearance of flat feet.Exercises will not correct flat feet.Flat feet cause no other orthopedic problems in infants.Corrective shoes will have no effect on strengthening the arches of the child's feet.

The parent of a 9-month-old infant is concerned that the infant's front soft spot is still open. What should the nurse tell the parent? "Your infant will need to be referred for more testing." "You should contact your health care provider immediately." "This is normal because this soft spot usually closes between 12 and 18 months." "I will measure your baby's head to see if it is a normal size."

"This is normal because this soft spot usually closes between 12 and 18 months." The anterior fontanelle, commonly known as the soft spot, closes between 12 to 18 months in most infants. The nurse normally measures an infant's occipital frontal circumference at each well-child visit. This action alone does not relieve the parent's concerns. Referrals would be indicated for premature or delayed closures of the fontanelle, especially if there were other abnormal findings. Closure of the anterior fontanelle by 12 months can only be expected to occur in approximately a third of all infants.

The unlicensed assistive personnel (UAP) obtained vital signs on a 7-month-old infant and recorded the peripheral pulse as 85 beats/minute. The RN immediately reassesses the child's pulse and discovers the pulse is 115 beats/minute. What should the nurse teach the UAP about obtaining an accurate heart rate in an infant? "Here is a copy of normal heart rates in children so you can report abnormal findings." "To assess a pulse in children, always assess the apical pulse." "To assess a pulse under age 1, you should check the brachial artery." "Always assess the pulse rate after you take the blood pressure."

"To assess a pulse in children, always assess the apical pulse." The apical pulse is the best location for evaluating the pulse of an infant younger than age 1, and a normal heart rate in this age group while awake is 100-160 beats/minute. The radial artery may not be easily palpable, causing missed beats and a potentially inaccurately low result. Providing a list of normal heart rates does not demonstrate the UAP knows how to obtain the pulse rate correctly. Taking the blood pressure first may irritate the child and cause crying, which can affect the accuracy of the heart rate assessment.

An 8-month-old infant is brought to the emergency department following a fall from a high chair and a possible head injury. The parents are distressed because the infant is crying and irritable. The mother asks if she can try to breastfeed the infant. What is the nurse's best response? "We can put you in a private area to feed, but we will need to reassess frequently." "Until assessments are complete, we should not give your child anything by mouth." "We can provide a bottle of water because clear fluids are best right now." "Yes, we recommend calming the child to reduce any increased pressures in the brain."

"Until assessments are complete, we should not give your child anything by mouth." The infant should be kept NPO until the possibility of a head injury with increased intracranial pressure is ruled out. The risk for aspiration still exists with providing bottled fluids. It would be inappropriate for the nurse to mention "increased pressures in the brain" in this scenario.

The mother of an infant being admitted to the hospital is crying and very upset. Which statement by the nurse would be most therapeutic? "Everyone here will take care excellent care of your infant." "What's making you cry right now?" "You did the right thing bringing him here when you did." "Please don't worry, everything's going to be all right."

"What's making you cry right now?" The nurse's best response is an open-ended question that gives the mother an opportunity to verbalize fears, share concerns, and ask for information.In this situation, the mother is right to be worried. Telling her to not do so would be inappropriate.Telling the mother that that everyone will take excellent care of her infant may be appropriate to say but only after determining the mother's feelings at the present time.Telling the mother that she did the right thing to bring her infant to the hospital does not address her concerns or needs at this time.

The nurse assesses infant development at a well-child clinic. Which infant most needs a developmental referral for a gross motor delay? 9-month-old who does not stand holding on 4-month-old who does not sit without support 2-month-old who does not roll over 6-month-old who does not crawl

9-month-old who does not stand holding on More than 90% of 9-month-olds are able to stand holding onto objects. Rolling over is expected at 4 to 6 months, and sitting without support is expected at 6 months. Crawling is expected at 9 months.

The nurse cares for an infant after surgical repair of a myelomeningocele. Which position should the nurse use to prevent musculoskeletal deformity in the infant? Maintain the knees in the neutral position. Place the feet in flexion. Allow the hips to be abducted. Place the legs in adduction.

Allow the hips to be abducted. Because of the potential for hip dislocation, the neonate's legs should be slightly abducted, hips maintained in slight to moderate abduction, and feet maintained in a neutral position. The infant's knees are flexed to help maintain the hips in abduction.

A 10-month-old child with bronchiolitis with a prescription to wean oxygen was weaned to room air 2 hours ago. During a feeding, the nurse notes that the child is exhibiting an increased respiratory rate, is becoming more irritable, and is using accessory muscles to breathe. The pulse oximeter is reading 91%. What should the nurse do first? Call for a stat PRN albuterol treatment and then complete the feeding. Discontinue the feeding and place the child back on oxygen. Assess the pulse rate and respirations and notify the primary care provider. Suction the child's nose with a bulb syringe and reassess the pulse oximeter.

Discontinue the feeding and place the child back on oxygen. The child who has increasing respiratory difficulty after being weaned from oxygen should be placed back on oxygen. The child's pulse rate will most likely be increased.The nurse does not need to notify the primary care provider of the child's status unless no improvement occurs after the child is back on oxygen.Albuterol has limited use in the treatment of bronchiolitis and can be associated with vomiting if given too close to feedings.Unless the child has blocked nasal passages, there is no reason to suction the nares.

During a well-baby visit, a parent asks the nurse when the infant should start receiving solid foods. The nurse should instruct the parent to introduce which solid food first? applesauce rice cereal egg whites yogurt

rice cereal The nurse should instruct the parent to introduce rice cereal first because it's easy to digest and is associated with few allergies. Next, the infant can receive pureed fruits, such as bananas, applesauce, and pears, followed by pureed vegetables, egg yolks, cheese, yogurt and, finally, meat. Egg whites shouldn't be given until age 9 months because they may trigger a food allergy.

Which action(s) should the nurse take prior to administering an oral medication to an infant? Select all that apply. Check the infant's pulse. Verify the infant's name. Ensure that it is the correct medication. Have the mother hold the infant. Verify that it is the correct dose.

Ensure that it is the correct medication. Verify that it is the correct dose. Verify the infant's name. The nurse should first ensure that the medication is the correct medication, is the correct dose, the correct route, and the correct client. The infant's pulse would only need to be checked if the medication being administered impacted the pulse. After these steps, the nurse should hold the infant securely in the crook of her arm and raise the infant's head to about a 45° angle. Then, the nurse should place the dropper at the corner of the infant's mouth so the drug runs into the pocket between the infant's cheek and gum. Doing this keeps him from spitting out the drug and reduces the risk of aspiration. After administering the medication, the nurse should document that the medication was given.

A nurse is conducting a physical examination on a 2-month-old infant at the well-child examination. When measuring chest circumference, what is the standard anatomical landmark used?

Head circumference and chest size measurements are often taken on newborns and infants to measure growth levels and development. These growth milestones reveal healthy brain growth and development. Chest circumference is most accurately measured by placing the measuring tape around the infant's nipples. Measuring above or below the nipples will yield a false measurement. The measurement would be taken after exhalation.

An infant goes into cardiac arrest. While conducting resuscitation, the team notes critical supplies are missing because the cart was not restocked properly by the nurses after an earlier arrest. The baby sustains brain damage as a result of delays in obtaining needed supplies. How does the nurse manager address this situation? Report the situation to the director of nursing so practice can be changed. Hold the nurses responsible because hospital procedure was not followed. Reassure the nurses that they will not be held liable for the negative outcome. Report that the pharmacy did not restock the medications missing from the cart.

Hold the nurses responsible because hospital procedure was not followed. Agency and hospital policies and procedures establish standards of care. If a nurse deviates from the standard, liability could result if an injury is sustained. In this case, the baby sustained brain damage because the nurses failed to follow the procedure for restocking the crash cart immediately after a code. The nurse needs to report to the pharmacy that the medications need to be restocked. The pharmacist cannot be blamed or held liable if they were not notified. The manager should not tell the nurses they will not be held liable. There is not evidence that current practice needs to be changed, just followed consistently.

Which nursing intervention is most important postoperatively for an infant who has received a ventriculoperitoneal shunt? Monitor intake and output. Initiate oral feedings. Allow the infant to rest undisturbed. Provide age-appropriate diversionary activities.

Monitor intake and output. In the postoperative period, intake and output are carefully monitored to prevent fluid overload that could lead to increased intracranial pressure.Feedings should start when the infant is fully awake.The infant will need to be disturbed to check vital signs and be repositioned.Age-appropriate activities are important but not until the infant is awake and less fussy.

The mother of a newborn is voicing concerns about her baby's ability to hear. What should the nurse tell the mother? Her concern is unfounded because hearing problems are rare in newborns. Newborns cannot hear well until they are at least 6 weeks old. She can test the baby's hearing by clapping her hands 24 inches (60 cm) from the infant's head. Most American states and Canadian jurisdictions mandate hearing tests for infants.

Most American states and Canadian jurisdictions mandate hearing tests for infants. The American Academy of Pediatrics and the American College of Obstetrics and Gynecology recommend hearing screening for all newborns. Currently more than 30 states mandate screening, which is done by otoacoustic emissions or auditory brainstem response. Newborns can hear as soon as the amniotic fluid drains from the ear canal. Even though hearing problems are not common in newborns, the mother's concerns should be addressed. Clapping to elicit a response is crude and unreliable. If done for minimal screening, the distance should be no more than 12 inches.

The nurse is giving care to an infant with a brain tumor. The nurse observes the infant arches their back (see figure). What action should the nurse take first? Notify the health care provider (HCP). Place the child prone. Stroke the back to release the arching. Pad the side rails of the crib.

Notify the health care provider (HCP). The infant has opisthotonos, an indication of brain stem herniation; the nurse should notify the HCP immediately and have resuscitation equipment ready. Stroking the back will not relieve the herniation or release the arching. Although the infant may also have a seizure, and padded side rails will prevent injury, the first action is to notify the HCP. Placing the child in a prone position will not relieve the herniation or release the arching.

While gently abducting the hips during a newborn assessment, the nurse hears a "click" as the femoral head slips into the acetabulum. The nurse interprets this as positive for which physical finding? Barlow's test Trendelenburg's sign Galeazzi's sign Ortolani's sign

Ortolani's sign Ortolani's sign refers to the "click" made when the femoral head slips forward into the acetabulum when forward pressure is exerted from behind the greater trochanter and the knee is held laterally. This sign indicates hip dislocation.A positive Barlow's test, evidenced by the femoral head slipping out over the acetabulum when pressure is applied then slipping back into place when the pressure is released, indicates that the hip is unstable with increased risk of dislocation.Galeazzi's sign refers to shortening of the affected limb in congenital hip dysplasia. It is elicited by flexing the infant's hips and knees while the infant lies supine. The soles of the feet are placed flat near the buttocks, and the knee heights are assessed for equality.Trendelenburg's sign refers to a downward tilting of the pelvis toward the normal side when a child with a dislocated hip stands on the affected side with the uninvolved leg elevated.

A parent phones the healthcare provider's office stating that a 13-month-old infant has had diarrhea for 3 days and the parent is unsure what fluids to offer. Which suggestions would the nurse provide? Select all that apply. whole milk Pedialyte® ginger ale cola apple juice water

Pedialyte® water The nurse is correct to instruct on oral rehydration fluids such as Pedialyte® or Lytren®. These solutions rehydrate with fluids and electrolytes and can be offered a teaspoon (5 mL) at a time. Water is also appropriate to provide fluids. The infant may need lactose-free products at this time. Apple juice, ginger ale, and cola have a high osmolality and may cause diarrhea.

The nurse is caring for an 8-month-old infant who was initially feeding well but is now failing to suck and swallow. Which of the following assessments should be a priority for the nurse based on this information? Palpate for an enlarged liver. Review recent urinary output. Perform a neurologic assessment. Assess bowel sounds.

Perform a neurologic assessment. Failure to suck and swallow may indicate neurologic deterioration. Central nervous system assessment always takes priority over other body systems to rule out CNS involvement.

After gathering all necessary equipment and setting up the supplies, what should be the first step in performing endotracheal (ET) or tracheal suctioning in an infant? Provide extra oxygen by using a ventilator or through manual bagging. Put on clean gloves. Insert a suction catheter to the appropriate measured length. Insert a few drops of sterile saline solution.

Provide extra oxygen by using a ventilator or through manual bagging. Providing extra oxygen before suctioning is the first step because it helps prevent hypoxemia. Insertion of a suction catheter is performed after preoxygenation. Instilling a few drops of sterile saline solution is no longer part of routine suctioning. ET and tracheal suctioning require sterile technique and sterile gloves, not just clean gloves.

A diagnosis of hemophilia A is confirmed in an infant. Which instruction should the nurse provide the parents as the infant becomes more mobile and starts to crawl? Administer one-half of a children's aspirin for a temperature higher than 101° F (38.3° C). Sew thick padding into the elbows and knees of the child's clothing. Check the color of the child's urine every day. Expect the eruption of the primary teeth to produce moderate to severe bleeding.

Sew thick padding into the elbows and knees of the child's clothing. As the hemophilic infant begins to acquire motor skills, falls and bumps increase the risk for bleeding. Such injuries can be minimized by padding vulnerable joints. Aspirin is contraindicated because of its antiplatelet properties, which increase the infant's risk for bleeding. Because genitourinary bleeding is not a typical problem in children with hemophilia, urine testing is not indicated. Although some bleeding may occur with tooth eruption, it does not normally cause moderate to severe bleeding episodes in children with hemophilia.

A young child has had a cardiac arrest, and the rapid response team has been activated. The nurse arrives in the client's room and observes a licensed practical/vocational nurse (LPN/VN) administering CPR to the child (see figure). What should the nurse do to assist the LPN/VN with CPR? Take over compressions using one hand while the LPN/VN uses a mask device to administer rescue breaths. Take over rescue breaths using a rate of 2 breaths per 15 compressions using a bag-mask device while the LPN/VN delivers compressions. Take over rescue breaths with a rate of 1 breath per 5 compressions using a bag-mask device while the LPN/VN continues compressions. Take over compressions at 80 compressions a minute while the LPN/VN uses a bag-mask device to administer rescue breaths.

Take over rescue breaths using a rate of 2 breaths per 15 compressions using a bag-mask device while the LPN/VN delivers compressions. The nurse should first obtain a bag-mask device and assist with CPR by giving breaths at a rate of two breaths for every 15 compressions. The LPN/VN is using the correct technique by using one hand on the chest to administer chest compressions. The heel of both hands is used for older children and adolescents. The compression rate is at least 100 per minute.

Which information obtained during the nursing history would help support a child's diagnosis of hemophilia? a brother and sister who are healthy a maternal uncle with prolonged postoperative bleeding paternal grandmother's death from chronic lymphocytic leukemia Italian and German ethnic background

a maternal uncle with prolonged postoperative bleeding Hemophilia A is a genetically transmitted, X-linked recessive disorder characterized by a deficiency of plasma factor VIII. A hemophiliac man and a normal woman have normal male children and female children who carry the hemophilia trait. The carrier females pass the abnormal gene to half their sons and the carrier trait to half their daughters. The mother's brother most likely has hemophilia, as evidenced by the prolonged postoperative bleeding. Thus, the mother may be a carrier.A healthy brother and sister would not suggest an underlying genetic disorder.Ethnic background is not related to the development of hemophilia.History of familial leukemia is unrelated to the development of hemophilia.

The mother of a 7-month-old infant who has had an inguinal herniorrhaphy and is fully recovered from anesthesia asks the nurse when they will be able to leave the day surgery unit. What should the nurse use as a criterion for discharge? cough reflex systolic blood pressure of 80 mm Hg ability to retain an oral feeding bowel movement

ability to retain an oral feeding Before discharge, the infant must be completely recovered from the anesthesia and be able to take and retain an oral feeding.Evidence of a cough reflex does not ensure that an infant can retain an oral feeding.A bowel movement may not occur for 24 hours. Thus, it is not a criteria for discharge.A normal systolic blood pressure reading for a 7-month-old infant is about 116 mm Hg. A reading of 80 mm Hg would be low, suggesting a potential problem.

The nurse assesses a 6-month-old child for vaccination readiness. Which finding would most likely indicate the need to delay administering the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine? temperature of 101.3°F (38.5°C) following the 4-month vaccinations acute bilateral ear infection family history of sudden infant death syndrome (SIDS) living with a family member who is immunosuppressed

acute bilateral ear infection Vaccination in the presence of a moderate-to-severe infection, with or without fever, increases the risk for injury and decreases the chance of mounting good immunity. An acute bilateral ear infection would constitute a moderate infection or illness. There is currently no evidence to suggest vaccines increase the risk for SIDS. A mild temperature may be expected with the DTaP vaccine. A temperature higher than (105°F (40.5°C) within 48 hours of vaccination would warrant caution. The DTaP vaccine is not a live vaccine. No special precautions are needed regarding immunosuppressed family members.

The parents of a healthy infant request information about advance directives. The nurse's best response is to ask open-ended questions to understand the parents' concerns. reassure the parents that advance directives are needed only for those who are likely to become ill. provide the parents with a brochure about advance directives. inform the parents that advance directives are a legal document and need a notary.

ask open-ended questions to understand the parents' concerns. Asking open-ended questions about the parents' concerns will help the nurse understand why they are asking for information. Advance directives are rarely prepared for healthy infants. The parents' request for information may indicate distress, and the nurse should obtain more details before giving them information. It is not necessary for the parents to discuss this with a lawyer as the infant is healthy. Providing the parents with a brochure about advance directives would help the parents understand what they are, but the nurse must obtain additional information.

The nurse is assessing the infant shown in the figure. On observing the client from this angle, the nurse should document that this infant has which finding? asymmetric gluteal folds Galeazzi sign Ortolani "click" limited abduction

asymmetric gluteal folds This infant with congenital hip dysplasia has asymmetric gluteal folds. The Ortolani "click" occurs when the nurse feels the femur sliding into the acetabulum with a click. Limited abduction may be observed during an attempt to abduct the infant's thighs. Galeazzi sign reveals femoral foreshortening and is observed by flexing the thighs.

A nurse is teaching child care classes for adolescent parents. To enhance the adolescents' understanding of infant safety, the nurse would suggest that the parent: discuss infant safety with the pediatrician. attend a lecture about poison control. review a video about pregnancy prevention. crawl around on the floor looking for potential hazards from the viewpoint of an infant.

crawl around on the floor looking for potential hazards from the viewpoint of an infant. Crawling on the floor is a participative activity that can help promote understanding of infant safety in relation to the infant's perspective. The nurse doesn't need to instruct adolescents to discuss infant safety with the pediatrician because the nurse can provide such information in the class environment. Presenting a lecture or video doesn't directly focus on the infant's perspective regarding items that may be a safety threat.

The nurse develops the discharge plan for the parents of an infant who has undergone a myelomeningocele repair. What information is most important for the nurse to include? schedule for daily home health care a list of available hospital services chaplain referral for psychological support daily care required by the infant

daily care required by the infant The most important aspect of the discharge plan is to ensure that the parents understand what the daily care of their infant involves and to provide teaching related to carrying out this daily care. In addition to the routine care required by the infant, care also may include physical therapy to the lower extremities. Providing a list of available hospital services may be helpful to the parents, but it is not the most important aspect to include in the discharge plan. Usually, home health care is not needed because the parents are able to care for their child. A referral for counseling is initiated whenever the need arises, not just at discharge.

A 3-month-old infant is admitted to the hospital to rule out nonaccidental trauma. X-ray findings indicate a fractured right humerus, fractured ribs, and a fractured left scapula. In this situation, a nurse is responsible for: ensuring that the suspected child abuse is reported to local authorities. contacting the infant's next of kin to begin discharge planning. contacting the local children's protective service office with an anonymous tip. reporting the suspicions to the hospital's chief of pediatric services.

ensuring that the suspected child abuse is reported to local authorities. Nurses must report suspicions of child abuse to local authorities. The contact procedure may vary among hospitals, but the nurse is responsible for making the report. Reporting suspected abuse to the hospital's chief of pediatric services isn't appropriate. Contacting the infant's next of kin to begin discharge planning is inappropriate because the infant may not be discharged to the next of kin. Providing an anonymous tip isn't appropriate behavior for a professional nurse. The hospital record is important to the legal process, and the nurse must handle it professionally.

The birth parent of an infant with myelomeningocele asks if the child is likely to have any other defects. The nurse responds based on the understanding that myelomeningocele is commonly associated with which disorder? abnormally small head congenital absence of the cranial vault excessive cerebrospinal fluid within the cranial cavity overriding of the cranial sutures

excessive cerebrospinal fluid within the cranial cavity Excessive cerebrospinal fluid in the cranial cavity, called hydrocephalus, is the most common anomaly associated with myelomeningocele. Microcephaly, an abnormally small head, is associated with maternal exposure to rubella or cytomegalovirus. Anencephaly, a congenital absence of the cranial vault, is a different type of neural tube defect. Overriding of the sutures, possibly a normal finding after vaginal birth, is not associated with myelomeningocele.

When performing an assessment on a one-day old newborn, which finding would be most suggestive of an imperforate anus? failure to pass a meconium stool hydrocele abdominal distention ribbon-like stools

failure to pass a meconium stool A newborn should pass stool within the first 24 hours of life. The absence of meconium stool is consistent with a diagnosis of imperforate anus because the neonate has no outlet to pass stool.Abdominal distention, a later sign of imperforate anus, occurs from the accumulation of gas and feces in the bowel.Ribbon-like stools are associated with anal stenosis.Hydrocele is not associated with anorectal malformations.

The administration of medications during infancy is often necessary. The nurse needs to be concerned about the metabolism of these drugs. What concern regarding metabolism should the nurse consider when administering medications to an infant? increased tubular secretion inefficient liver function decreased glomerular filtration reduced protein-binding ability

inefficient liver function Inefficient liver function will most likely decrease drug metabolism during infancy. As the liver matures during the first year of life, drug metabolism improves. Decreased glomerular filtration and increased tubular secretion may affect drug excretion rather than metabolism; reduced protein-binding ability may affect drug distribution but not metabolism.

The nurse assesses a 4-month-old infant diagnosed with possible intussusception. The nurse should expect the parent to relate which information about the infant's crying and episodes of pain? constant accompanied by leg extension shrill during ingestion of solids intermittent with knees drawn to the chest intermittent while being held in the parent's arms

intermittent with knees drawn to the chest The infant with intussusception experiences acute episodes of colic-like abdominal pain. Typically, the infant screams and draws the knees to the chest. Between these episodes of acute abdominal pain, the infant appears comfortable and normal. Feeding does not precipitate episodes of pain. Additionally, a 4-month-old infant typically would not be ingesting solid foods. Pain exhibited by crying that occurs when the infant is placed in a reclining position, as in the parent's arms, is not associated with intussusception. This type of cry may indicate that the infant wants attention, wants to be held, or needs to have a diaper change.

The emergency department nurse has admitted an infant with bulging fontanelles, setting sun eyes, and lethargy. Which diagnostic procedure would be contraindicated in this infant? computerized tomography scan lumbar puncture arterial blood draw magnetic resonance imaging

lumbar puncture The child is exhibiting signs and symptoms of increased intracranial pressure (ICP). A lumbar puncture is contraindicated in children with increased ICP due to the risk for herniation. Magnetic resonance imaging and a computerized tomography scan are indicated in children with suspected increased ICP. Radiology studies will allow visualization of the cause of the increased ICP, such as inflammation, a tumor, or hemorrhage. An arterial blood draw is not indicated in this client. However, there is no contraindication for performing an arterial blood draw on a child with increased ICP.

When developing the plan of care for a child diagnosed with phenylketonuria (PKU), the nurse should establish which goal? ensuring that the special diet is started at age 3 weeks meeting the child's nutritional needs for optimal growth maintaining serum phenylalanine level lower than 2 mg/100 mL (120 µmol/L) maintaining serum phenylalanine level higher than 12 mg/100 mL (720 µmol/L)

meeting the child's nutritional needs for optimal growth The goal of care is to prevent intellectual disabilities by adjusting the diet to meet the infant's nutritional needs for optimal growth. The diet needs to be started upon diagnosed, ideally within a few days of birth. Serum phenylalanine level should be maintained between 3 and 7 mg/100 mL (180 to 420 ?mol/L). Significant brain damage usually occurs if the level exceeds 10 to 15 mg/100 mL (600 to 900 ?mol/L). If the level drops below 2 mg/100 mL (120 ?mol/L), the body begins to catabolize its protein stores, causing growth restriction.

A nurse is caring for a 12-month-old infant with dehydration with resulting metabolic acidosis. The infant exhibits lethargy and poor skin turgor. Which action by the nurse takes priority? obtaining blood cultures offering the infant sucralose by bottle obtaining a patent intravenous site obtaining a urine sample via catheterization

obtaining a patent intravenous site The nurse's priority is to correct the dehydration by first obtaining a patent IV line for the administration of fluids and medications. Obtaining a blood sample for a white blood count and blood cultures and a urine sample will not change the outcome of the need for fluid and electrolyte correction.

A 4-month-old infant is diagnosed with congenital hypothyroidism and prescribed levothyroxine. When should the nurse teach the parents to administer the medication? regardless of meals on an empty stomach 30 minutes after meals with the nighttime formula

on an empty stomach Levothyroxine should be taken on an empty stomach to facilitate absorption. All the other responses could reduce absorption and cause subtherapeutic levels.

The parents of a child with sickle cell anemia ask about the chances of sickle cell disease occurring in future children. What does the nurse determine is the family's risk of having another child with sickle cell anemia? one chance in five for each pregnancy one chance in three for each pregnancy one chance in two for each pregnancy one chance in four for each pregnancy

one chance in four for each pregnancy Sickle cell disease is an autosomal recessive Mendelian disorder. Therefore, if both parents have the trait, there is a one-in-four chance that any child (each pregnancy) will have the disease and a one-in-two chance that a child (each pregnancy) will have the trait.

A 6-month-old infant is assessed to have 4% volume depletion related to a gastrointestinal illness. What intervention would the nurse recommend to the parents based on the infant's condition? oral electrolyte replacement solutions, breast milk, or lactose-free formula BRAT diet (bananas, rice, apples, and toast or tea) until stools are firm IV fluid replacement therapy and nothing per oral (NPO) for next 48 hours clear fluids, such as fruit juices, carbonated soft drinks, and gelatin

oral electrolyte replacement solutions, breast milk, or lactose-free formula A volume depletion of 4% is considered mild and is based on total body water loss calculated via percentage of weight loss. In cases of mild hypovolemia, oral electrolyte replacement solutions, breast milk, or lactose-free formula may be given in small amounts. IV fluids are usually reserved for clients experiencing moderate to severe hypovolemia, and the treatment requires hospitalization. Fruit juices, carbonated soft drinks, and the BRAT diet, all of which are high in carbohydrates and low in electrolytes, are not recommended.

The nurse positions a neonate with an unrepaired myelomeningocele. Which position is most appropriate? right side-lying position with the knees flexed supine in semi-Fowler position with the chest and abdomen elevated supine with the hips at 90-degree flexion prone with the hips in abduction

prone with the hips in abduction Before surgery, the infant is kept flat in the prone position to decrease tension on the sac. This allows for optimal positioning of the hips, knees, and feet because orthopedic problems are common. The supine position is unacceptable because it causes pressure on the defect. Flexing the knees when side-lying will increase tension on the sac, as will placing the infant in semi-Fowler position, even though the chest and abdomen are elevated.

The nurse works with the health care team to establish a policy regarding sleep positions for infants with gastroesophageal reflux. What information should the nurse search for first? data from retrospective studies published national standards policies from other hospitals expert opinions

published national standards Published national standards are based on the best evidence and, when available, should serve as the foundation for nursing unit policies. Policies from other hospitals may or may not be evidence based. Retrospective studies and expert opinions should only be used to form policy when data from experimental studies or national standards are not available.

When developing the preoperative plan of care for an infant with Hirschsprung's disease, the nurse should include which intervention? restricting oral intake to clear liquids inserting a gastrostomy tube using povidone-iodine solution to prepare the perineum administering a tap water enema

restricting oral intake to clear liquids Before intestinal surgery, dietary intake is limited to clear liquids for 24 to 48 hours. A clear liquid diet meets the child's fluid needs and avoids the formation of fecal material in the intestine. Typically, repeated saline enemas, not tap water enemas, are given to empty the bowel. Soapsuds enemas are contraindicated for infants, as are tap water enemas. A nasogastric tube may be inserted for gastric decompression. Insertion of a gastrostomy tube is outside the scope of nursing practice. Because the perineal area is not involved in the surgery, it does not need to be prepared.

The nurse assesses an 8-month-old child's language development. Which finding would the nurse consider to be typical language development? saying "dada" to father and "mama" to mother saying mama" and "dada" while pointing to the parent saying "dada" and "mama" nonspecifically. saying three other words besides "mama" and "dada."

saying "dada" and "mama" nonspecifically. It is important for the nurse to assist parents in assessing speech development in their child so that developmental delays can be identified early. At 8 months of age, the child should say "mama" and "dada" nonspecifically and imitate speech sounds. Children cannot say "dada" or "mama" specifically or use more than three words until they are about 12 months of age. A child cannot respond to specific commands or point to objects when requested until about 17 months of age.

What liquid does the nurse recommend the parents of a 1½-month-old infant with hypothyroidism use to administer levothyroxine with? large amount of water small amount of formula or breast milk infant's bowl of cereal milk or orange juice

small amount of formula or breast milk Placing the dissolved pill in a small amount of formula or expressed breast milk would be acceptable for this infant because doing so helps to ensure that the infant will take all the medication.Mixing medications in large amounts of fluid such as water is not recommended because the infant may not take all the liquid. Thus, the parents would not know if the child received the correct dose.Mixing the medication with milk, juice, or cereal is contraindicated for this infant, who would not be taking these foods yet.

The nurse is assessing a 6-month-old and notices no pincer grasp on either hand. The parent asks the nurse if this is abnormal. The nurse correctly responds that: the physician will need to ask questions about the infant's siblings and their development. the 6-month-old does not normally have a pincer grasp yet. the physician will be in to check the child and the parent can ask the physician. the infant may be at risk for developmental disabilities.

the 6-month-old does not normally have a pincer grasp yet. The nurse would be incorrect to inform the parent that the infant could be at risk for developmental disabilities, because the pincer grasp does not present itself until around 9 months of age. Deferring the question to the physician is ignoring the mother's concern, and the nurse can manage this question. There is no need to ask the physician about the infant's other siblings.

An infant who has been in foster care since birth requires a blood transfusion. Who will the nurse approach to give written, informed consent for the procedure? the social worker for the foster home a Child Protective Services representative the foster mother the nurse manager

the foster mother When children are minors and aren't emancipated, their parents or designated legal guardians are responsible for providing consent for medical procedures. Therefore, the foster mother is authorized to give consent for the blood transfusion. The social worker, the nurse, and the nurse manager have no legal rights to give consent in this scenario. Child Protective Services would become involved only if there was a disagreement between the healthcare provider's recommendation and the foster mother's willingness to consent to treatment.

For the past 6 days, a 7-month-old infant has been receiving amoxicillin trihydrate to treat an ear infection. Now the parents report redness in the diaper area and small, red patches on the infant's inner thighs and buttocks. After diagnosing Candida albicans, the physician orders topical nystatin to be applied to the perineum four times daily. The nurse should focus her assessment on: the inside of the infant's mouth. the infant's height and weight. the infant's fontanels. the infant's heart and respiratory rate.

the inside of the infant's mouth. The nurse should pay close attention to the inside of the infant's mouth for white patches. Signs of thrush, these patches are common in children with C. albicans infections and should be reported to the physician. Although the other assessments should be performed as a part of an infant evaluation, they aren't the nurse's primary focus in this situation.

The health care team determines that the family of an infant with failure to thrive who is to be discharged will need follow-up care. Which approach would be the most effective method of follow-up? twice-weekly clinic appointments weekly visits by a community health nurse daily phone calls from the hospital nurse enrollment in community parenting classes

weekly visits by a community health nurse The most effective follow-up care would occur in the home environment. The community health nurse can be supportive of the parents and will be able to observe parent-infant interactions in a natural environment. The community health nurse can evaluate the infant's progress in gaining weight, offer suggestions to the parents, and help the family solve problems as they arise.

The parents of a 3-week-old healthy newborn ask the nurse why their child is intermittently cross-eyed. What is the nurse's best response? "It is normal to have eye-crossing in the newborn period." "Your child will likely need an ophthalmology consult." "An eye patch may be necessary to correct your child's vision." "Surgery may be necessary to correct your child's vision."

"It is normal to have eye-crossing in the newborn period." During the first few months of life, an infant's eyes may wander and appear to be crossing. As the eye muscles mature, between 2 and 3 months of age, both eyes will focus on the same thing. No intervention is necessary, as crossing of the eyes is normal in the first few months of life.

Assessment of a 6-week-old infant reveals weight and length in the 50th percentile for his age and a head circumference at the 95th percentile. What should the nurse do first? Obtain a written consent for transillumination. Assess motor and sensory function of the legs. Examine the fontanels and sutures. Advise the mother of the need for follow-up in 1 month.

Examine the fontanels and sutures. Head circumference usually parallels the percentile for length. The discrepancy found requires close and immediate attention because it could indicate hydrocephalus with its potential for brain damage. Therefore, the nurse should examine the fontanels and sutures. In an infant, bulging fontanels and widening cranial sutures are signs of increasing intracranial pressure related to increased cerebrospinal fluid in the cranial space.Assessing motor and sensory function of the legs would be done if the fontanel or sutures were abnormal.Since the infant requires immediate attention, follow-up in 1 month is inadequate.Transillumination is a noninvasive procedure used to assess hydrocephalus. It does not require a written consent and would be performed after examining the fontanel and sutures.

The nurse is caring for an infant with a congenital heart defect. What priority health teaching should the nurse offer to the parents of this infant? Your child will need oxygen at home. There are no restrictions on play. Keep feedings small, but frequent. It is dangerous to let your child cry.

Keep feedings small, but frequent. Because children with heart defects fatigue so quickly, frequent small meals are suggested to ensure that the child receives adequate nutrition. Rough play would be considered too physically demanding on the child. Most children do not need oxygen at home.

The nurse is caring for the following infant after surgery. Which short term goal is the priority? The infant will continue breastfeeding 3 to 5 times daily. The infant will bond with parents by holding and cuddling during each visit. The infant will maintain 5 to 7 moderately wet diapers daily. The infant will remain infection free in the postoperative period.

The infant will remain infection free in the postoperative period. The client has spinal bifida with a myelomeningocele (protrusion of the spinal cord and meninges). Surgery is completed within the first days of life. Following surgery and in the recovery period, it is most important to maintain meticulous care to the incision to reduce the potential for infection. Infection can spread through the incision and up the spinal tract to the brain. All other goals are important but not as great a priority as infection.

An infant is hospitalized for treatment of inorganic failure to thrive. Which nursing action is most appropriate for this child? rotating caregivers to provide more stimulation keeping the infant on bed rest to conserve energy maintaining a consistent, structured environment encouraging the infant to hold a bottle

maintaining a consistent, structured environment The nurse caring for an infant with inorganic failure to thrive should strive to maintain a consistent, structured environment because it reinforces a caring feeding environment. Encouraging the infant to hold a bottle would reinforce an uncaring feeding environment. The infant should receive social stimulation rather than be confined to bed rest. The number of caregivers should be minimized to promote consistency of care.

A nurse is teaching the parent of a 5-month-old infant diagnosed with bronchiolitis. Which statement by the mother indicates that teaching has been effective? "I hope my baby will come home from the hospital." "I know that this disease is serious and can lead to asthma." "My baby has been sick. A machine will help him breathe." "My baby needs to be cured this time so it won't happen again."

"I know that this disease is serious and can lead to asthma." By saying that bronchiolitis places the child at risk for developing asthma, the parent demonstrates understanding of the infant's condition. If diagnosed and treated promptly, most infants recover from the illness and return home. Infants typically don't have recurrences of bronchiolitis. Infants diagnosed with bronchiolitis rarely require mechanical ventilation.

After teaching a community class to new parents, the nurse evaluates client understanding of strategies to prevent sudden infant death syndrome (SIDS). Which statements indicates appropriate understanding? "I will keep my baby's crib at our bedside when we sleep." "I will place my baby in a supine position for sleep during the first year." "I will avoid feeding my baby cereal for the first 6 months." "I will use a baby monitor so I can hear if my baby stops breathing."

"I will place my baby in a supine position for sleep during the first year." SIDS has no specific cause but occurs most often in male infants who were low birth weight, were placed on their stomachs for sleep, and had mothers who used tobacco or alcohol. Caucasian infants have a lower risk than children of color. SIDS can occur anytime between ages 1 week and 1 year. The incidence peaks at ages 2-4 months.

An infant who weighs 7.5 kg is to receive ampicillin 25 mg/kg intravenously every 6 hours. How many milligrams would the nurse administer per dose? Record your answer using one decimal place.

187.5 The nurse would calculate the correct dose using the following equation:25 mg/kg × 7.5 kg = 187.5 mg

A nurse is caring for an infant who weighs 8 kg and is ordered to receive ampicillin 25 mg/kg intravenously every 6 hours. How many milligrams would a nurse administer per dose? Record the answer as a whole number.

200 The nurse would calculate the correct dose by multiplying the infant's weight by the ordered rate:8 kg x 25 mg/kg = 200 mg.

A physician orders an intravenous infusion of dextrose 5% in quarter-normal saline solution (D5.25 NSS) to be infused at 7 ml/kg/hour for a 10-month-old infant. The infant weighs 22 lb (10 kg). How many milliliters of the ordered solution would the nurse infuse each hour? Record your answer using a whole number.

70 To perform this dosage calculation, the nurse would first convert the infant's weight to kilograms if needed (in the United States):2.2 lb/kg = 22 lb/XX = 22/2.2 kgX = 10 kg.Next, the nurse would multiply the infant's weight by the ordered rate:10 kg x 7 ml/kg/hour = 70 ml/hour.

The nurse is caring for an infant diagnosed with thrush. Which instruction would the nurse give to a client's mother who will be administering nystatin oral solution? Administer the drug right before meals by using a gauze pad. Mix the drug with small amounts of formula in bottle. Administer the drug right after meals by dabbing the solution to the sites. Administer half the dose before and half after a feeding.

Administer the drug right after meals by dabbing the solution to the sites. Nystatin oral solution is an antifungal medication used to treat fungal or yeast infections. Nystatin oral solution should be swished around the mouth after eating for the best contact with mucous membranes. For an infant, the medicated solution is placed directly on the sites as they cannot follow directions to swish. Taking the drug before or with meals does not allow for optimal contact with mucous membranes.

Which action should the nurse include when developing the plan of care for a neonate prior to surgical repair of a myelomeningocele? Position the neonate on the side. Leave the defect exposed to air. Cover the defect with moist, sterile saline dressings. Apply thin layers of tincture of benzoin around the defect.

Cover the defect with moist, sterile saline dressings. The sac is kept moist by covering it with nonadherent, sterile saline dressings. The dressings will need to be moistened often to prevent them from drying out. The sac also is inspected carefully for leaks, abrasions, and signs of infection.Tincture of benzoin is an adherent and should not be used, because it could potentially cause disruption of the neonate's skin integrity.The neonate should be positioned on the abdomen to avoid tearing the sac.The sac must be kept moist. If left open to the air, it would dry out, possibly causing the sac to tear, which would allow cerebrospinal fluid to leak.

A nurse is caring for an infant who is in critical condition. The nurse notes that the child weighs 11 lb (5 kg) and has had a blood loss of 100 mL. Assessment reveals a decreased urine output, mild tachycardia, and restlessness. Which of the following should be the priority action for the nurse to take? application of telemetry monitoring insertion of a Foley indwelling catheter neurologic assessment with the Glasgow Coma Scale IV administration of lactated Ringer's

IV administration of lactated Ringer's The loss of small volumes of blood in children is significant and can lead to hypovolemic shock. In this situation, the blood loss represents approximately 10% of the child's total blood volume. Because the child is exhibiting signs of early hypovolemic shock, the priority action should be the administration of Ringer's lactate for fluid resuscitation. The remaining options may need to be implemented, but the priority is to correct the fluid deficit.

An infant requires tracheal suctioning after the nurse assesses airway congestion. Which is the priority initial action when performing the procedure? instilling saline solution donning clean gloves oxygenation prior to the procedure inserting a suction catheter to the appropriate length SUBMIT ANSWER

oxygenation prior to the procedure Providing extra oxygen before suctioning is the first step because it helps prevent hypoxemia. Insertion of a suction catheter is performed after preoxygenation. Instilling saline solution is not a recommended part of routine suctioning. Tracheal suctioning requires sterile technique and sterile gloves, not just clean gloves.

The nurse is teaching the parents of a 5-month-old infant who has been prescribed digoxin. What teaching will the nurse include in the infant's plan of care? Select all that apply. giving the medication at different times in the day assessing the infant's apical pulse monitoring the infant for signs of toxicity monitoring the infant's urinary output administering medication with food

assessing the infant's apical pulse monitoring the infant's urinary output monitoring the infant for signs of toxicity Monitoring the heart rate is necessary prior to administration. Monitoring the client's urinary output will assist in assessment of the client's renal status. Digoxin should be given on an empty stomach. Monitoring for signs of toxicity is important and includes assessing for nausea, vomiting, anorexia, diarrhea, restlessness, drowsiness, fatigue, and visual disturbances. The medication should be given at the same time every day.

The nurses discusses appropriate iron-rich food selections with the parent of an 11-month-old infant with iron deficiency anemia. The nurse determines that teaching has been successful when the parent verbalizes that she will include which foods in the child's diet? juices, fruits, fortified cereals, and milk eggs, fortified cereals, meats, and green vegetables eggs, fruits, milk, and mixed vegetables fruits, cereals, milk, and yellow vegetables

eggs, fortified cereals, meats, and green vegetables Relatively high amounts of iron are contained in eggs, fortified cereals, meats, and green vegetables. Juices, fruits, yellow or mixed vegetables, and milk contain less iron and are not the best choices.

An infant is having a 2-month checkup at the pediatrician's office. The physician tells the parents that the infant is being assessed for Ortolani's sign. The nurse explains that the presence of Ortolani's sign indicates dislocation of the: hip. shoulder. knee. elbow.

hip. To assess for Ortolani's sign, the physician abducts the infant's hips while flexing the legs at the knees. This is performed on all infants to assess for congenital hip dislocation. The examiner listens and feels for a "click" as the femoral head enters the acetabulum during the examination. This finding indicates a congenitally dislocated hip.

Which action should a nurse include in the care plan for a 2-month-old infant with heart failure? Bathe the infant and administer medications before feeding. Allow the infant to rest before feeding. Weigh and bathe the infant before feeding. Feed the infant when the infant cries.

Allow the infant to rest before feeding. Because feeding requires so much energy, an infant with heart failure should rest before feeding. Bathing and weighing the infant and administering medications should be scheduled around feedings. An infant expends energy when crying; therefore, it's best if the infant doesn't cry.

The physician suspects tracheoesophageal fistula in a 1-day-old neonate. Which nursing intervention is most appropriate for this child? avoiding suctioning unless cyanosis occurs elevating the neonate's head and giving nothing by mouth giving the neonate only glucose water for the first 24 hours elevating the neonate's head for 1 hour after feedings

elevating the neonate's head and giving nothing by mouth Because of the risk of aspiration, a neonate with a known or suspected tracheoesophageal fistula should be kept with the head elevated at all times and should receive nothing by mouth (NPO). The nurse should suction the neonate regularly to maintain a patent airway and prevent pooling of secretions. Elevating the neonate's head after feedings or giving glucose water are inappropriate because the neonate must remain on NPO status.

After surgery to repair a cleft lip, an infant has a Logan bow in place. Which postoperative nursing action is appropriate? burping the infant less frequently placing the infant on the abdomen after feedings holding the infant semi-upright during feedings removing the Logan bow during feedings

holding the infant semi-upright during feedings Holding the infant semi-upright during feedings is appropriate because it helps prevent aspiration. The Logan bow must be kept in place at all times to protect the suture line. The infant should be burped more frequently to prevent regurgitation and aspiration. Placing the infant on the abdomen could lead to disruption of the suture line if the infant rubs the face.

In which parts of the body should the nurse administer an intramuscular injection to a 6-month-old infant? between the greater trochanter and the posterior superior iliac spine between the greater trochanter, the iliac crest, and the anterior superior iliac spine the lateral middle third of the thigh between the greater trochanter and the knee two finger breadths below the acromion process on the lateral side of the arm

the lateral middle third of the thigh between the greater trochanter and the knee The appropriate site to give an injection to an infant is the vastus lateralis. The dorsogluteal, ventrogluteal, and deltoid muscles are areas for older children and adults.

At a 6-month well-child check, an infant has a high fever and cold symptoms and is diagnosed with otitis media. The child is scheduled to receive the 6-month immunizations. The parent asks the nurse if the child will receive them. What is the nurse's best response? "Your child must be free of infection for 6 months before resuming the immunizations." "Make an appointment to come back for the immunizations after your child has finished the antibiotics." "Your child will receive just the hepatitis immunization today because of the illness." "Your child should have a pneumonia shot today instead."

"Make an appointment to come back for the immunizations after your child has finished the antibiotics." A common reaction to immunizations is malaise and fever. It is recommended that children who are already moderately to severely ill recover first before receiving any immunization. Once the child is well, normal immunizations can be given. The child does not need to wait 6 months.

A nurse is teaching parents about the nutritional needs of their full-term infant, age 2 months, who's breast-feeding. Which response shows that the parents understand their infant's dietary needs? "We should add new fruits to the diet one at a time." "We'll introduce cereal into the diet now." "We won't start any new foods now." "We'll start the baby on skim milk."

"We won't start any new foods now." The parents show understanding of their infant's dietary needs by stating they won't start any new foods. Breast milk provides all the nutrients a full-term infant needs for the first 6 months. They shouldn't provide skim milk because it doesn't have sufficient fat for infant growth. The parents also shouldn't provide solid foods, such as cereal and fruit, before age 6 months because an infant's GI tract doesn't tolerate them well.

Which of the following should the nurse use to determine achievement of the expected outcome for an infant with severe diarrhea and a nursing diagnosis of Deficient fluid volume related to passage of profuse amounts of watery diarrhea? Passage of a soft, formed stool. Ability to tolerate intravenous fluids well. Absence of diarrhea for a 4-hour period. Moist mucous membranes.

Moist mucous membranes. The outcome of moist mucous membranes indicates adequate hydration and fluid balance, showing that the problem of fluid volume deficit has been corrected. Although a normal bowel movement, ability to tolerate intravenous fluids, and an increasing time interval between bowel movements are all positive signs, they do not specifically address the problem of deficient fluid volume.

Which nursing activity supports the principles of palliative care for a dying infant and the infant's family? clustering care activities to provide as much rest as possible for the infant minimizing noise and disruption to decrease stress for the infant maintaining routines and structure for the infant and the infant's family creating a therapeutic, homelike environment for the infant and the infant's family

creating a therapeutic, homelike environment for the infant and the infant's family The goal of palliative care is to make the infant and the infant's family as comfortable as possible. Maintaining routines and structure doesn't support the principles of palliative care. Clustering care activities may allow the infant more rest, but this action isn't a principle of palliative care. Minimizing noise and disruption isn't specifically related to palliative care.

At a previous visit, the parents of an infant with cystic fibrosis received instruction in the administration of pancrelipase. At a follow-up visit, which finding in the infant suggests that the parents require more teaching about administering the pancreatic enzymes? bloody stools liquid stools fatty stools normal stools

fatty stools Pancreatic enzymes normally aid in food digestion in the intestine. In a child with cystic fibrosis, however, these natural enzymes cannot reach the intestine because mucus blocks the pancreatic duct. Without these enzymes, undigested fats and proteins produce fatty stools. If the parents were administering the pancreatic enzymes correctly, the child would have stools of normal consistency. Noncompliance doesn't cause liquid or bloody stools.

A nurse is administering I.V. fluids to an infant. Infants receiving I.V. therapy are particularly vulnerable to: hypotension. pulmonary emboli. cardiac arrhythmias. fluid overload.

fluid overload. Infants, small children, and children with compromised cardiopulmonary status receiving I.V. therapy are particularly vulnerable to fluid overload. To prevent fluid overload, the nurse should use a volume-control set and an infusion pump or syringe and place no more than 2 hours' worth of I.V. fluid in the volume-control set at a time. Hypotension, cardiac arrhythmias, and pulmonary emboli aren't problems associated with I.V. therapy in infants.

A mother and infant are admitted to the emergency department following a motor vehicle collision. The mother has a Glasgow coma scale score of 6. The parents are divorced and have joint custody of the infant. The infant's father was not involved in the collision and arrives in the emergency department. Who should the nurse contact about consent for treatment of the infant? Child Protective Services representative infant's mother infant's father mother's listed next of kin

infant's father The father may give consent for treatment of the infant because he has legal custody. Even if verbal, the mother should not be asked for consent, because the current Glasgow coma scale result meets the criteria for severe brain injury (score less than 8 out of a possible 15). The mother's next of kin should be contacted for consent for her treatment (if needed) but not for the infant's treatment as the father is the infant's next of kin. Because the father may give consent for the infant to be treated, it isn't necessary to contact Child Protective Services.

A 10-month-old infant with tetralogy of Fallot (TOF) experiences an cyanotic episode. To improve oxygenation during such an episode, the nurse should place the infant in which position? Fowler's prone knee-to-chest Trendelenburg's

knee-to-chest TOF involves four defects: pulmonary stenosis, right ventricular hypertrophy, ventricular-septal defect (VSD), and dextroposition of the aorta with overriding of the VSD. Pulmonary stenosis decreases pulmonary blood flow and right-to-left shunting via the VSD, causing desaturated blood to circulate. The nurse should place the child in the knee-to-chest position because this position reduces venous return from the legs and increases systemic vascular resistance, maximizing pulmonary blood flow and improving oxygenation status. Fowler's, Trendelenburg's, and the prone positions don't improve oxygenation.

A 3-month-old infant just had a cleft lip and palate repair. To prevent trauma to the operative site, the nurse should: place the infant in the prone position. give a pacifier to help soothe the infant. place the infant's arms in soft elbow restraints. avoid touching the suture line.

place the infant's arms in soft elbow restraints. Soft restraints from the upper arm to the wrist are appropriate because they prevent the infant from touching the lip but allow the infant to hold a favorite item such as a blanket. Because they could damage the operative site, such objects as pacifiers, suction catheters, and small spoons shouldn't be placed in an infant's mouth after cleft palate repair. An infant in a prone position may rub his face on the sheets and traumatize the operative site. The suture line should be cleaned gently to prevent infection, which could interfere with healing and damage the cosmetic appearance of the repair. Dried blood collecting on the suture line can widen the scar.

When administering an oral medication to an infant, the nurse should take which action to decrease the risk of aspiration? Keep the infant upright, gently pinch the child's nostrils to encourage the infant's mouth to open, then administer the medication slowly. Use an oral syringe to place the medication beside the tongue, and administer the medication as quickly as possible. Use an oral syringe to place the medication beside the tongue, and administer the medication slowly. Place the medication in the infant's bottle of formula and encourage the infant to suck.

Use an oral syringe to place the medication beside the tongue, and administer the medication slowly. Using an oral syringe is the best way to prevent aspiration because it allows controlled administration of a small amount of medication. Administering the medication too quickly may cause aspiration. Putting the drug in a bottle of formula isn't preferred because the infant may not take the entire dose of medication and the contents of the bottle could interfere with drug absorption or action. Blocking the nasal passages could cause aspiration.

A nurse should assess the maturity of enzyme systems (kidney and liver) in which pediatric population before administering medications? adolescents premature infants toddlers neonates

premature infants Factors related to growth and maturation significantly alter an individual's capacity to metabolize and excrete drugs. Thus, the premature infant is at risk for problems because of immaturity. Deficiencies associated with immaturity become more important with decreasing age. Enzyme systems develop quickly, with most increasing to adult levels within 1 to 8 weeks after birth. Within the first year of life, all are probably as active as they will ever be.

When discussing an infant's motor skill development with the mother, the nurse should explain that by age 7 months, an infant most likely will be able to perform which skill? sitting alone using the hands for support eating successfully with a spoon standing while holding onto furniture walking with one hand held

sitting alone using the hands for support By age 6 months, an infant can sit alone, leaning forward on the hands for support. The ability to sit follows progressive head control and straightening of the back.By 12 months, an infant can walk with one hand held.At about 18 months, an infant can eat successfully with a spoon.At 11 months, an infant can stand and walk while holding onto furniture.

The parents of an infant with myelomeningocele ask the nurse about their child's future mental ability. What is the nurse's best response? "About one-third have an intellectual disability, but it is too early to tell about your child." "Intellectual disabilities occur in about two-thirds of these children, and you will know soon if this will occur." "Your child will probably be of normal intelligence since they demonstrate signs of it now." "You will need to talk with the health care provider (HCP) about that, but you can ask later."

"About one-third have an intellectual disability, but it is too early to tell about your child." Approximately one-third of infants diagnosed with myelomeningocele have an intellectual disability, but the degree of disability is variable, and it is difficult to predict intellectual functioning in neonates. The parents are asking for an answer now and should not be told to talk with the HCP later.

After undergoing surgical correction of pyloric stenosis, an infant is returned to the room in stable condition. While standing by the crib, the parent says, "Perhaps if I had brought my baby to the hospital sooner, the surgery could have been avoided." What is the nurse's best response? "Do you think that earlier hospitalization could have avoided surgery?" "Surgery is the most effective treatment for pyloric stenosis." "Try not to worry; your baby will be fine." "Do you feel that this problem indicates that you are not a good parent?"

"Do you think that earlier hospitalization could have avoided surgery?" Restating or rephrasing a parent's response provides the opportunity for clarification and validation. It also helps to focus on what the parent is saying and address their concerns and feelings. Although surgery is the most effective treatment for pyloric stenosis, stating this ignores the parent's feelings and does not give them an opportunity to express them. Telling the parent not to worry also ignores the parent's feelings. Additionally, this type of statement gives the parent premature reassurance, which may turn out to be false. Asking the parent if they think the problem indicates that they are not a good parent implies such an idea. It does not allow the parent to express their concerns and feelings and therefore is not a therapeutic response.

The nurse is discharging a newborn with clubfoot who has had a cast applied. The nurse should provide additional teaching to the parents if they make which statement? "Having a cast should not prevent me from holding my baby." "I should use a pillow to elevate my child's foot as they sleep." "My baby will need a series of casts to fix their foot." "I should call if I see changes in the color of the toes under the cast."

"I should use a pillow to elevate my child's foot as they sleep." Elevating the extremity at different points during the day is helpful to prevent edema, but pillows should not be used in the crib because they increase the risk for sudden infant death syndrome (SIDS). A change in the color of the toes is a sign of impaired circulation and requires medical evaluation. Children typically need a series of 5 to 10 casts to correct the deformity. Infants with clubfeet still need frequent holding like any other newborn.

The nurse obtains the nursing history from the parent of an infant with suspected intussusception. Which question would be most helpful for the nurse to ask? "What do the stools look like?" "Is your child eating normally?" "Has your child had any episodes of vomiting?" "When was the last time your child urinated?"

"What do the stools look like?" For the infant with intussusception, stools characteristically have the appearance of currant jelly because of the intestinal inflammation and hemorrhage resulting from intestinal obstruction. These stools occur later in the course of the disease process. Questions that focus on urination, vomiting, and food intake do not elicit information about the effects of intussusception.

While examining an 11-month-old child, the nurse notes that the child can stand independently but cannot walk without support. How should the nurse intervene? Tell the mother that the child may have a developmental delay. Recommend the child uses a walker at home. Initiate a consultation with a developmental specialist. Do nothing because this is a normal finding in a child this age.

Do nothing because this is a normal finding in a child this age. An 11-month-old child is expected to cruise but not necessarily walk without support. Use of a walker at home are not recommended because they may tip and increase the risk for falls. A developmental specialist consult is not necessary. Even if the child's development in walking is slow, this fact is not sufficient data to make the nurse suspect developmental delay.

The nurse is planning care with the parents of a 4-month-old infant with heart failure and congenital heart disease. The parents report that their child tires easily. Which intervention is a priority for this child? Add layers of clothing Increase the number of rest periods. Prevent infection. Restrict the child's movements.

Increase the number of rest periods. An infant with congenital heart disease and congestive heart failure usually tires easily due to lack of effective oxygenation. Nursing care needs to focus on allowing the infant to have frequent rest periods.Infants with congenital heart disease and heart failure are not necessarily at risk for more infections than other infants.An infant with congenital heart disease usually exhibits normal physical mobility, and the parents should encourage normal growth and development. The child's movements are not the cause of the fatigue. Additional layers of clothing may lead to overheating and are not necessary unless the child presents with symptoms of temperature instability.

A parent tells the nurse that their 8-month-old infant is anxious. Which suggestion by the nurse is most appropriate to help the parent lessen anxiety in the infant? Limit holding the infant to feeding times. Talk quietly to the infant while he is awake. Have a close friend keep the infant for a few days. Play music in his room for most of the day and night.

Talk quietly to the infant while he is awake. Infants are sensitive to stress in their caretakers. The best way to handle an anxious infant is to talk quietly, thereby soothing the infant. Limiting holding of the infant to feeding periods interferes with meeting the infant's needs for close contact, possibly compromising his ability to develop trust. Playing music in the room for most of the day and night will make it difficult for the infant to differentiate days from nights. Having a friend take the infant for several days will not necessarily take care of the problem because when the infant returns to the parents, the same behaviors will recur unless the parents makes some changes.

An infant undergoes surgery to correct an esophageal atresia and tracheoesophageal fistula. Which nursing diagnosis has the highest priority during the first 24 hours postoperatively? impaired tissue perfusion ineffective airway clearance risk for aspiration imbalanced nutrition: less than body requirements

ineffective airway clearance Ineffective airway clearance has the highest priority in the immediate postoperative period. The infant's airway must be carefully assessed, and frequent suctioning may be necessary to remove mucus while taking care not to pass the catheter as far as the suture line. The nurse should assess breath sounds, respiratory rate, skin color, and ease of breathing. Because of the risk of edema and airway obstruction, keep a laryngoscope and endotracheal intubation equipment readily available. There could be impaired tissue perfusion from the edema, but keeping the airway patent is the priority. The risk for aspiration is present, but a risk does not take priority over an actual nursing problem. Imbalanced nutrition can occur because the infant is unable to ingest any food—nutrients must be provided via enteral or parenteral nutrition—but this diagnosis does not have priority over the airway.

After an infant undergoes surgical repair of a cleft lip, the physician orders elbow restraints. For this infant, the postoperative care plan should include which nursing action? removing the restraints while the infant is asleep removing the restraints every 2 hours keeping the restraints on both arms only while the child is awake using the restraints until the infant recovers fully from anesthesia

removing the restraints every 2 hours Removing one elbow restraint at a time every 2 hours for about 5 minutes allows exercise of the arms and inspection for skin irritation. To prevent the infant from touching and disrupting the suture line, the nurse should use the restraints when the infant is asleep and awake. The nurse should maintain the elbow restraints from the time the infant recovers from anesthesia until the suture line is healed.

The nurse gives anticipatory guidance to the parents of a 5-month-old infant about toy safety. What toys should the nurse recommend? plastic toy cars soft, washable toys stuffed animals wooden puzzles

soft, washable toys Soft, washable toys are appropriate for infants, who tend to place everything in their mouths. These toys are not harmful. Plastic toys cannot be manipulated by a child of this age, and the child would put the car in the mouth, which may not be safe due to small parts that may be swallowed or aspirated. Games and puzzles are too advanced for a 5-month-old, and the child could put the pieces in the mouth and swallow them. Some stuffed animals have eyes that can be swallowed or aspirated.

The breastfeeding parent of a 1-month-old diagnosed with cow's milk sensitivity asks the nurse what they should do about feeding their infant. Which recommendation would be most appropriate? "Discontinue breastfeeding, and start using a predigested formula." "Continue to breastfeed, but eliminate all milk products from your own diet." "Change to a soy-based formula exclusively, and begin solid foods." "Limit breastfeeding to once per day, and begin feeding an iron-fortified formula."

"Continue to breastfeed, but eliminate all milk products from your own diet." Parents of infants with a cow's milk allergy can continue to breastfeed if they eliminate cow's milk from their diet. It is important to encourage birth parents to continue to breastfeed because breast milk is usually the least allergenic and most easily digested food for an infant. In addition, the infant is able to obtain protein through the birth parent's milk. If the parent stops breastfeeding, a predigested protein hydrolysate formula would be the first choice. An iron-fortified formula is a cow's milk-based formula. A soy-based formula is not used because approximately 20% of infants with cow's milk sensitivity are also sensitive to soy. Solid foods are not introduced until the infant is 4 to 6 months of age.

While performing an assessment, a nurse observes a 6-month-old infant transferring an object from one hand to another and reaching for the nurse's stethoscope. The parent tells the nurse this is new behavior and asks if it is normal. The nurse educates the parent about growth and development parameters for a 6-month-old infant. What does she tell the parent? "Your baby has very advanced gross motor skills." "This is an example of your baby exhibiting personal-social skills." "This is a skill that your baby should have been exhibiting at 2 months of age. We will continue with further assessment since this is a developmental delay." "This behavior is typical for a 6-month-old infant."

"This behavior is typical for a 6-month-old infant." The nurse should say this behavior is normally seen because an infant typically transfers objects from one hand to another and reaches for objects between ages 4 and 6 months, so the infant is demonstrating normal developmental behavior. This is a fine-motor adaptive skill, not a personal-social skill. A 2-month-old grasping a rattle is an example of a fine-motor adaptive skill.

The nurse assesses an 8-month-old infant for a possible head injury after a fall of about 3 feet. The child is awake, alert, and crying. Vital signs are within normal limits. What action should the nurse take next? Apply 100% supplemental oxygen. Obtain immediate intravenous access. Assess the infant's pupillary responses. Interview the parents about the fall.

Assess the infant's pupillary responses. With a possible head injury in an infant, the nurse must complete a neurological assessment that includes assessing pupillary response. A fall from 3 feet is considered a significant distance for an infant. Changes in normal pupil response can indicate increased intracranial pressure. The infant's crying indicates a patent airway, and vital signs are normal, which satisfies breathing and circulation. There is no indication the infant requires supplemental oxygen or intravenous therapy at this point. The nurse should complete the initial assessments to ensure the infant is stable prior to taking the time to interview the parents further.

During the nurse's assessment, the newborn wakes and is in a quiet-alert state. The nurse counts the apical pulse to be 157 beats per minute. Which is the most appropriate nursing action? Call the pediatrician because this finding is dangerously high. Document this finding as on the high end of the normal range and plan to reassess. Notify the charge nurse because this finding is on the low end of the normal range given the newborn's quiet-alert state. Document this finding as on the low end of the normal range and plan to reassess.

Document this finding as on the high end of the normal range and plan to reassess. Heart rates can be as fast as 180 bpm, but the normal range for a newborn heart rate is 110-160 bpm. Thus, the newborn's heart rate of 157 bpm is on the high end of the normal range, but still within the normal range. It would be appropriate to reassess the client's heart rate because newborn heart rates can fluctuate depending on the state of consciousness/wakefulness, hunger, temperature, and especially if the newborn is moving or startled. It would be inappropriate to call the pediatrician or to notify the charge nurse at this time because the value is currently within the normal range.

An IV infusion is to be administered through a scalp vein on an infant's head. What should the nurse tell the parents to prepare them for the procedure? A sedative will be given to the infant to help keep the child quiet. Visiting the infant will be delayed until the infusion has been completed. Holding the infant will be contraindicated while the infusion is being administered. It may be necessary to remove a small amount of hair from the infant's scalp.

It may be necessary to remove a small amount of hair from the infant's scalp. Parents are typically quick to notice changes in their infant's physical appearance. The removal of the infant's hair may be upsetting to them if they have not been told why it is being done. Hair may be removed on the scalp at the site of needle insertion for IV therapy to provide better visualization and a smooth surface on which to attach tape to secure the needle. Sedatives are not ordinarily prescribed before IV fluid administration. In most instances, it is acceptable for parents to visit their infant while the IV solution is infusing. Holding the infant is encouraged to provide comfort.

A 4-month-old infant has been carried into the emergency department after falling off the parents' bed and hitting the head on the floor. What should the nurse do first? Move the family to an area where an assessment can be completed and call for a physician. Notify the supervisor that an operating room is needed because the physician will want to insert a ventriculoperitoneal (VP) shunt. Call child protective services because of suspected child endangerment. Assess the infant's vital signs in the triage area and instruct the family to wait until their names are called.

Move the family to an area where an assessment can be completed and call for a physician. A head injury in an infant can be extremely serious. The nurse's priority should be to move the infant and family to an area where assessment and treatment can occur. Triaging the infant and having the parents wait for evaluation by a physician is inappropriate because of the potential seriousness of the injury. Although increased intracranial pressure can result from head trauma, it's unlikely that inserting a VP shunt would be the first treatment. The fact that the child was left unattended in an unsafe location is a significant safety issue, but notifying child protective services isn't a priority at this time.

A day-shift nurse on the pediatric neurologic unit has just received a report from the previous shift. Which infant should the nurse assess first? an infant whose pulse is 140 bpm an infant whose respirations are between 38 and 50 breaths per minute An infant with an axillary temperature of 100.4°F (38°C) on the third postoperative day a restless infant with a high-pitched cry who was transferred from the intensive care unit (ICU) the previous evening

a restless infant with a high-pitched cry who was transferred from the intensive care unit (ICU) the previous evening An infant's restlessness and high-pitched cry can indicate increased intracranial pressure (ICP). Because the infant was transferred from the ICU the previous night, assessing for increased ICP should be a nursing priority. The infant with a pulse of 140-160 bpm exhibits normal parameters. Although the nurse must assess a low-grade fever on the third postoperative day, this stable infant isn't the priority at this time. Decreased respirations are indicative of increased intracranial pressure, but this infant's respirations of 38 breaths per minute would not be a priority concern.

Which behavior exhibited by the parent of an infant with pyloric stenosis should the nurse correctly interpret as a positive indication of parental coping? telling the nurse that they have to get away for a while discussing the infant's care realistically exhibiting fear that they will disturb the infant repeatedly asking if their child is normal

discussing the infant's care realistically The parents' ability to verbalize the infant's care realistically indicates that they are working through their fears and concerns. This behavior demonstrates an understanding of the infant's condition and needs. Without further data, the fact that the parents have to get away could be interpreted as ineffective coping, possibly suggesting that they are unable to handle the situation. Continuing to ask about the child's general condition even after answers have been given does not suggest effective coping. The parents are demonstrating that they are unsure of themselves as parents or are hoping for positive information. Exhibiting fear that they will disturb the infant does not suggest effective coping. This behavior indicates that they are uncertain or lack knowledge about infants.

When the nurse is teaching a group of parents about common childhood problems, a parent asks, "Why are children more likely to develop ear infections than adults are?" The nurse bases the response to this question on the understanding that the key anatomic difference between adults and children is due to which structure? ear canals tympanic membranes nasopharynx eustachian tubes

eustachian tubes In infants and young children, the eustachian tubes are short and lie in a relatively horizontal position. This anatomic position favors the development of otitis media because it is easy for materials from the nasopharynx to enter the tubes.Although bacteria may be present in the nasopharynx, this does not affect middle ear function.The size of the ear canal has no impact on the increased number of ear infections in children. An intact tympanic membrane prevents bacteria from entering the middle ear from the external ear canal. The tympanic membrane changes appearance with an ear infection, but its structure does not predispose infants and young children to ear infection.

A nurse is caring for an infant who requires intravenous therapy. The nurse notes that the only available IV pump is in a toddler's room. In which order should the nurse complete the following actions?1. Remove pump from toddler's room.2. Clean the pump.3. Take pump into infant's room.4. Use the pump. 1, 3, 2, 4 2, 1, 3, 4 1, 2, 3, 4 2, 3, 1, 4

1, 2, 3, 4 Properly cleaning the monitoring equipment is the correct infection control process. Best practices would include removing the pump from the toddler's room, cleaning the pump, taking the pump into the infant's room, and using the pump.

Before surgery, a neonate is to receive an IM injection of an antibiotic. Which gauge and size of needle should the nurse select? 20G, 1" (2.5 cm) needle 19G, 1 1/2" (3.8 cm) needle 25G, 5/8" (1.6 cm) needle 23G, 2" (5 cm) needle

25G, 5/8" (1.6 cm) needle When administering an IM injection to most term neonates, a 25G to 27G, 5/8? (1.6 cm) long needle is appropriate.A 19G, 1 1/2? (3.8 cm) needle is too large for an infant.A 20G 1? (2.5 cm) needle is too large for an infant.A 23G, 2? (5 cm) needle is too large for an infant.

A parent brings a 3-month-old infant to the clinic, reporting that the infant has a cold, is having trouble breathing, and "just does not seem to be acting right." Which action should the nurse take first? Weigh the infant. Check the infant's heart rate. Obtain more information from the father. Assess the infant's oxygen saturation.

Assess the infant's oxygen saturation. In an infant with these symptoms, the first action by the nurse would be to obtain an oxygen saturation reading to determine how well the infant is oxygenating. Because the parent probably can provide no other information, checking the heart rate would be the second action done by the nurse. Then the nurse would obtain the infant's weight.

A parent reports that they think their infant has colic. Which information should the nurse obtain next from the parent? the type of formula the infant is taking the infant's crying pattern the position of the infant during burping the infant's sleep position

the infant's crying pattern Information on the crying pattern of the infant is most helpful in confirming the diagnosis of colic. Typically, the colic attack begins abruptly, with the infant crying loudly and continuously, possibly for hours. The attack may end when the child becomes exhausted. The child also may attain some relief after passing stool or flatus. Often, in an attempt to alleviate the infant's crying, parents try to feed the infant, resulting in overfeeding, leading to discomfort and distention. Asking about the type of formula, sleep position, or position for burping will not provide sufficient information to confirm the diagnosis of colic. However, the nurse can obtain additional information after determining the nature of the crying pattern.

The nurse lifted up a neonate from the bassinet. The neonate became startled, extended the arms with hands open and started crying. What intervention would be most appropriate for the nurse? Document the finding as a normal response. Do a complete neurological examination. Contact the health care provider. Give the neonate a pacifier.

Document the finding as a normal response. The Moro or startle reflex is present in all neonates up until 3 to 4 months of age. It has three components: spreading out the arms (abduction), pulling the arms in (adduction), and crying. With the arms outstretched, the palms of the hands are up and open with the thumbs being flexed. This reflex occurs as a response to a sudden loss of support. It is a normal response, so the nurse would document as such. There is no need to notify the health care provider or do a neurological exam. A pacifier will not prevent the Moro reflex but it may help soothe the neonate after being startled. Even though it is a caring intervention it is not the most important. The most important is to know if the reflex is present or absent.

A parent brings a 2-month-old infant to the clinic for a well-baby checkup. Which setting would be best for the nurse to assess the interaction between parent and infant? as the infant sleeps as the infant watches a mobile as the parent rocks the infant as the parent feeds the infant

as the parent feeds the infant The nurse can best assess parent-infant interaction during feeding, such as by observing how closely the parent holds the infant and how the parent looks at the infant's face. These behaviors help reveal the parent's anxiety level and overall feelings for the infant. The infant's posture and response during feeding provide clues to the infant's comfort level and feelings. Sleeping does not provide an opportunity for parent-infant interaction. Although playing and rocking may provide clues about parent-infant interaction, they are not the best activities to assess. During playing, for example, the parent may interact with the infant at a distance, whereas rocking promotes closeness but not interaction; the parent can rock the infant while talking to someone else or staring off into the distance.

The nurse determines the parents' compliance with treatment for their infant who has otitis media. Which behavior would indicate that the parents are adhering to the treatment plan? administering continuous, low-dose antibiotic therapy cleaning the child's ear canals with hydrogen peroxide holding the child upright when feeding with a bottle instilling ear drops regularly to prevent cerumen accumulation

holding the child upright when feeding with a bottle Sitting or holding a child upright for formula feedings helps prevent pooling of formula in the pharyngeal area. When the vacuum in the middle ear opens into the pharyngeal cavity, formula (along with bacteria) is drawn into the middle ear. Cleaning the ear canals does not reduce the incidence of otitis media because the pathogenic bacteria are in the nasopharynx, not the external area of the ears. Continuous low-dose antibiotic therapy is used only in cases of recurrent otitis media, when the child finishes a course of antibiotics but then develops another ear infection a few days later. Although accumulation of cerumen makes it difficult to visualize the tympanic membrane, it does not promote inner ear infections.

After having trouble breastfeeding, a 6-week-old female infant exhibits dry, scaly skin and a protruding tongue. A diagnosis of congenital hypothyroidism is made. The mother asks the nurse why the child was not diagnosed with this condition at birth. What would be the nurse's best response? "Your baby had little need for thyroid hormone until she was 1 month old." "Newborns generally receive enough thyroid hormone from the mother to get by the first few weeks." "We had the results of the newborn screen, but you didn't bring the baby in for the 2-week checkup." "We couldn't reach you at home to give you the results of tests taken at birth."

"Newborns generally receive enough thyroid hormone from the mother to get by the first few weeks." With congenital hypothyroidism, failure of normal development occurs during the embryonic period or when an inborn error of metabolism prevents the normal synthesis of thyroxine. Although the condition is present at birth, maternal thyroxine can pass through the placenta to the fetus, supplying the fetus and neonate sufficiently. Thus, in most neonates, the signs of hypothyroidism are commonly masked at birth. Telling the mother that she did not bring the child in for the 2-week checkup implies that the mother was at fault, possibly causing the mother to become defensive. Telling the mother that she could not be reached is not therapeutic and may cause the mother to become defensive.

The nurse is caring for an infant who exhibits the above characteristics. When planning care, which would be the best long term client goal? The client will reach his/her optimal level of functioning. The client will care for himself/herself without supervision. The client will express his/her thoughts and feelings. The client will feed himself/herself independently.

The client will reach his/her optimal level of functioning. Down syndrome results from trisomy of chromosome 21 and is evidenced by various physical and cognitive impairments. Common physical characteristics include a flat, broad nasal bridge, inner epicanthal folds, slanted eyes, a protruding tongue, a short neck, hypotonia and a palmar crease. Nursing interventions include supporting the parents through the diagnostic process, monitoring for cardiac or respiratory problems with a long term goal to help to assist the client to reach his optimal level of functioning. Specific goals include feeding, personal care and communication skills.

The nurse assesses an infant with a suspected inguinal hernia. Which finding would be most concerning? The inguinal swelling is reddened, and the abdomen is distended. The infant's diaper is wet with urine, and the abdomen is nontender. The infant is irritable, and a thickened spermatic cord is palpable. The inguinal swelling can be reduced, and the infant has stool in their diaper.

The inguinal swelling is reddened, and the abdomen is distended. Abdominal distention and redness of the inguinal swelling are significant findings. Their presence in conjunction with area tenderness and inability to reduce the hernia indicate an incarcerated hernia. An incarcerated hernia can lead to strangulation, necrosis, and gangrene of the bowel. Other findings associated with strangulation include irritability, anorexia, and difficulty in defecation. A strangulated hernia necessitates immediate surgical intervention. The ability to reduce the hernia and normal stooling do not indicate it is incarcerated. Irritability is nonspecific and could be caused by various factors. A palpable, thickened spermatic cord on the affected side is diagnostic of inguinal hernia and would be an expected finding. A wet diaper indicates that urine is being excreted, a finding unrelated to inguinal hernia.

A 6-month-old on the pediatric floor has a respiratory rate of 68, mild intercostal retractions, and oxygen saturation of 89%. The infant has not been feeding well for the last 24 hours and is restless. Using the situation, background, assessment, and recommendation (SBAR) technique for communication, the nurse calls the health care provider (HCP) with the recommendation for which treatment? transferring the child to pediatric intensive care providing sedation prescribing a chest CT scan starting oxygen

starting oxygen The infant is experiencing signs and symptoms of respiratory distress indicating the need for oxygen therapy. Sedation will not improve the infant's respiratory distress and would likely cause further respiratory depression. If the infant's respiratory status continues to decline, they may need to be transferred to the pediatric intensive care unit. Oxygen should be the priority as it may improve the infant's respiratory status. A chest CT is not indicated. However, a CXR would be another appropriate recommendation for this infant.

An infant admitted to the hospital with an acute rotavirus infection is having frequent diarrheal stools. On assessment, the nurse notes 40 to 60 bowel sounds per minute. The child has poor skin turgor and dry mucous membranes. The nurse determines the infant's dehydration is related to which factor? increased GI motility insufficient antidiuretic hormone decreased gastric emptying inability to metabolize nutrients

increased GI motility Rotavirus is a type of viral infection that affects the GI tract. It causes diarrhea, which results in fluid loss. This type of infection can be very serious in infants who, because of their immature kidneys, cannot adjust to fluid loss as readily as adults.Acute diarrheal infection results in increased gastric emptying.Insufficient production of antidiuretic hormone is not a consequence of acute diarrheal infection.Acute diarrheal infection results in malabsorption, not an inability to metabolize nutrients that are absorbed.

An infant's death is deemed due to sudden infant death syndrome (SIDS). The parents want to know the cause of SIDS and if they could have done something to prevent it. What explanation should the nurse provide these parents? "Unfortunately the cause of SIDS is unknown." "SIDS occurs only in premature infants." "SIDS occurs in babies who sleep on their abdomen." "SIDS occurs after an upper respiratory infections."

"Unfortunately the cause of SIDS is unknown." Unfortunately, while there are many theories as what causes SIDS, no one specific cause has been identified. SIDS is more frequent in male than female infants. Although cigarette smoke may have an association with SIDS, exposure to respiratory infection has not been proven to be correlated with an increased incidence of SIDS. Although SIDS is more common in preterm infants, it is often associated with multiple births, infants with low Apgar scores, and infants born to mothers who smoked during pregnancy. SIDS can also occur in babies who sleep face down on soft surfaces. That is why back sleeping is now recommended.

A premature infant has been placed on a home apnea monitor. The nurse is giving discharge instructions to the parents. The nurse begins teaching by stating "Using the monitor will help your physician determine the frequency of apneic events and how long monitoring is required." "You can only give your baby sponge baths until monitoring is discontinued because it's dangerous to take the monitor off at any time." "Your baby will probably need to be monitored until at least age 1." "Remove the monitor at least 3 hours per day to allow the baby a rest period."

"Using the monitor will help your physician determine the frequency of apneic events and how long monitoring is required." Home apnea monitoring helps the physician determine the frequency of apneic events and how long monitoring is required. Use of home monitoring has been helpful in improving neonatal survival. The average length of monitoring is 6 weeks; only occasionally is it required beyond 1 year. The monitor can be removed for bathing and during times when parent or caregiver is physically present and actively engaged with the care of the infant.

Which finding indicates that the infant has adequately evacuated the barium after undergoing a barium enema? absence of fecal mass in the lower abdomen stool guaiac that is negative stools that progress from clay-colored to brown bowel sounds of 30 per minute

stools that progress from clay-colored to brown The presence of barium produces white or clay-colored stools. A change in stool color from clay-colored to normal brown is an indication that the barium has been evacuated.Presence or absence of a fecal mass does not give definitive information about the passage or retention of barium.Bowel sounds of 30 per minute suggest normal functioning but do not necessarily indicate passage of barium.A stool guaiac test is done to determine the presence of occult blood not barium.

A parent asks the nurse why a 10-month-old infant gets otitis media more frequently than a 10-year-old child. How should the nurse respond? "Pressure builds up in the ear canal when infants lie flat." "Infants under one year have immature immune systems." "An infant's eustachian tubes are shorter." "Infants are unable to blow their own noses."

"An infant's eustachian tubes are shorter." Infants and young children are more prone to otitis media because their eustachian tubes are shorter and lie more horizontally. Pathogens from the nasopharynx can more readily enter the eustachian tube of the middle ear. The tendency toward otitis media isn't related to the ability to blow the nose or to lying flat. The baby's immune system may not be as developed as the older child's, but that is not the reason for recurrent otitis media.

An 8-month-old infant is brought to the emergency department (ED) following a fall from his high chair. The child is awake, alert, and crying. Which nursing intervention would be most appropriate for the nurse? Surgical evacuation of suspected cerebral hyperemia Immediate admission to the pediatric unit Discharge to home with instructions to the parents for head injury Monitoring the child for 24 hours in the ED, then discharge to home if no complications are noted

Discharge to home with instructions to the parents for head injury The child is showing no signs of deficit from head injury at this time and should therefore be discharged with instructions to the parents on what to look for in the subsequent hours following the fall. Given that the child is awake and alert, there are no signs that further observation or admission is required, nor is there any indication for surgery at this time.

Which measure would be most effective in helping the infant with a cleft lip and palate to retain oral feedings? Burp the infant at frequent intervals. Maintain the infant in a supine position while feeding. Feed the infant small amounts at one time. Place the end of the nipple far to the back of the infant's tongue.

Burp the infant at frequent intervals. An infant with a cleft lip and palate typically swallows large amounts of air while being fed and therefore should be burped frequently. The soft palate defect allows air to be drawn into the pharynx with each swallow of formula. The stomach becomes distended with air, and regurgitation, possibly with aspiration, is likely if the infant is not burped frequently. Feeding frequently, even in small amounts, would not prevent swallowing of large amounts of air. A nipple placed in the back of the mouth is likely to cause the infant to gag and aspirate. Holding the infant in a supine position during feedings can also lead to regurgitation and aspiration of formula. The infant should be fed in an upright position.

A 1-year-old child is admitted to the hospital with sickle cell crisis. Which intervention does the nurse anticipate will be included in the child's plan of care? exchange transfusion fast-acting anticoagulant therapy parenteral iron therapy IV fluid therapy

IV fluid therapy During a sickle cell crisis, increasing the transport and availability of oxygen to the body's tissues is paramount. Administering a high volume of IV fluid and electrolytes to help compensate for the acidosis resulting from hypoxemia associated with sickle cell crisis is one way to accomplish this. Fluid administration also helps overcome dehydration, a possible predisposing factor common in children with sickle cell crisis.Iron therapy is contraindicated for this condition.Exchange transfusions are used only in certain situations, such as severe hyperbilirubinemia. Small amounts of blood are removed from the infant and replaced with whole blood. This helps to correct the anemia and lower bilirubin levels.Although anticoagulants have been suggested, they are not included in the usual treatment of sickle cell crisis.

The caregiver of a 2-month-old client calls stating that the client is "fussy and has a runny nose." The caregiver states that the client has been sleeping poorly at night and is not eating as well. Which of the following interventions will the nurse teach the caregiver? Give the client an over-the-counter cough-and-cold medicine. Have the caregiver make an appointment with the healthcare provider for antibiotics. Use a bulb syringe to suction out the nasal passages. Encourage the caregiver to administer aspirin as needed for fever.

Use a bulb syringe to suction out the nasal passages. Children under 2 years of age should not take over-the-counter cough-and cold-medications. The symptoms that the caregiver is describing are for the common cold and antibiotics are not needed. Aspirin is contraindicated in children for the treatment of a fever due to the risk of Reye's syndrome. A bulb syringe to suction out the nasal passages of the client is an appropriate intervention.

The nurse teaches the parents of a neonate who has undergone corrective surgery for tracheoesophageal fistula about the need for long-term health care. The nurse bases the teaching on the child's high risk for which condition? esophageal stricture gastric ulcers speech problems recurrent mild diarrhea with dehydration

esophageal stricture After corrective surgery for repair of tracheoesophageal fistula (TEF), the risk for esophageal stricture is high because scar tissue forms at the site of the esophageal anastomosis, commonly requiring dilation at the anastomosis site during the first years of childhood in about half of such children.Speech problems are likely if other abnormalities are present to produce them. However, the larynx and structures of speech are not affected by TEF.Although dysphagia and strictures may decrease food intake and poor weight gain may result, gastric ulcers are not associated with TEF repair.Recurrent mild diarrhea with dehydration typically does not develop from surgery to correct TEF.

A nurse is obtaining the history of an infant with suspected acute otitis media. What should the nurse ask the parent about? covering of the infant's ears when out in the cold thorough drying of the infant's ears after a bath immunization status of the infant position of the infant when taking a bottle

position of the infant when taking a bottle A significant association between feeding position and otitis media exists. Children fed in a supine position have a high incidence of otitis media because of the reflux of milk into the eustachian tubes during feedings. Keeping the infant's ears covered when out in the cold or thoroughly drying the ears after a bath has not been identified as a contributing factor to an infant's development of ear infections. Although the infant's immunization status is always important to ascertain, other factors, such as the position of the infant when taking a bottle, have more impact.

The nurse maintains the airway of an infant with a tracheoesophageal fistula (TEF). Which finding would most indicate that the infant needs suctioning? substernal retractions increased respiratory rate decreased activity level barking cough

substernal retractions With a TEF, an overflow of secretions into the larynx leads to laryngospasm. This obstruction to inspiration stimulates the strong contraction of accessory muscles of the thorax to assist the diaphragm in breathing. This produces substernal retractions. The laryngospasm that occurs with a TEF resolves quickly when secretions are removed from the oropharynx area. A barking cough is related to a relatively constant laryngeal narrowing, usually caused by edema seen with croup. It is not an indication of the need to suction. A decreased activity level and an increased respiratory rate in an infant with a TEF are usually the result of hypoxia, a relatively long-term and constant phenomenon in infants with a TEF.

A parent is concerned about spoiling a 2-month-old child by picking up the child each time the child cries. Which suggestion should the nurse offer? "If the baby's diaper is dry, leave the baby alone to fall asleep." "Continue to pick up the crying baby because young infants need cuddling and holding to meet their needs." "Leave your baby alone for 10 minutes. If the crying hasn't stopped then, pick up the baby." "Crying at this age indicates hunger. Try feeding when your baby cries."

"Continue to pick up the crying baby because young infants need cuddling and holding to meet their needs." The nurse should advise the parent to continue to pick up the crying infant because a young infant needs to be cuddled and held when crying. Because the infant's cognitive development isn't advanced enough to associate crying with getting attention, it would be difficult to spoil the infant at this age. Even if the diaper is dry, a gentle touch may be necessary until the infant falls asleep. Crying for 10 minutes wears an infant out; ignoring crying can make the infant mistrust caregivers and the environment. Infants cry for many reasons, not just when hungry, so the parent shouldn't assume the infant is crying from hunger.

The nurse teaches the parents of an infant with clubfoot requiring application of a plaster cast how to care for the cast. Which statement would indicate that the parents have understood the teaching? "The petals on the edge of the cast can be removed after the first 24 hours." "We will elevate the leg with the cast on pillows so the leg is above heart level." "We will check the color and temperature of the toes of the casted leg frequently." "If the cast becomes soiled, we will clean it with soap and water."

"We will check the color and temperature of the toes of the casted leg frequently." A cast that is too tight can cause a tourniquet effect, compromising the neurovascular integrity of the extremity. Manifestations of neurovascular impairment include pain, edema, pulselessness, coolness, altered sensation, and inability to move the distal exposed extremity. The toes of the casted extremity should be assessed frequently to evaluate for changes in neurovascular integrity. Wetting a plaster cast with water and soap softens the plaster, which may alter the cast's effectiveness. There is no reason to elevate the casted extremities when a child with clubfoot is being treated with nonsurgical measures. The legs would be elevated if swelling were present. Petals, which are applied to cover the rough edges of the cast, are to be left in place to minimize the risk for skin irritation from the cast edges.

The mother says that the infant's primary care provider recommends certain foods, but the infant refuses to eat them after breastfeeding. How should the nurse suggest that the mother alter the feeding plan? Offer breast milk as long as the infant refuses to eat solid foods. Allow the infant to nurse for a few minutes and then offering solid foods. Mix pureed food with some breast milk in a bottle with a large-holed nipple. Offer dessert followed by some vegetables and meat.

Allow the infant to nurse for a few minutes and then offering solid foods. It is typical for an infant just starting on solid foods to spit them out because the infant does not know how to swallow them. Also, the infant is hungry and is accustomed to having milk to satisfy that hunger. It is generally recommended that an infant be given some milk first and then offered solid foods.Offering dessert followed by vegetables and meat is inappropriate because the infant will learn to prefer the sweets first and then possibly refuse the vegetables and meats.Offering breast milk as long as the infant refuses solid foods is inappropriate because an infant who fills up on breast milk will have no interest in the solids.Mixing pureed foods with breast milk is inappropriate because solid food should be given with a spoon. Also, using a large-holed nipple may cause the infant to choke from getting too much fluid at one time.

The nurse is caring for a 9-month-old child who was admitted with severe dehydration after several days of diarrhea. The child has completed initial rehydration therapy. The nurse is instructing the parents on the best way to maintain adequate fluids. Which course of treatment should the nurse recommend? Offer fruit juices and gelatin as the child will tolerate. Encourage the child to take chicken or beef broth. Place the child on a low-residue diet for several days. Continue with breast milk or lactose-free formula.

Continue with breast milk or lactose-free formula. Water, breast milk, and lactose-free formula are low-sodium fluids that are often used during maintenance fluid therapy. Fruit juices, carbonated soft drinks, and gelatin have a high carbohydrate content, very low electrolyte content, and high osmolarity, so they are not used to manage diarrhea. Caffeinated soda is a mild diuretic, so its use may lead to increased loss of water and sodium. Chicken or beef broth has excessive sodium and inadequate carbohydrate content. The BRAT (bananas, rice, applesauce, and toast or tea) diet has little nutritional value.

When assessing the chest of a 4-month-old infant, the nurse identifies the ratio of the anteroposterior-to-lateral diameter as 1:1. What action should the nurse take next? No action is needed; this is a normal finding. Check the infant for signs of respiratory distress. Instruct the parents to bring the infant back in 1 month for reevaluation. Inform the physician of the finding and obtain an order for a chest X-ray.

No action is needed; this is a normal finding. No action is needed by the nurse because in an infant, the anteroposterior diameter is normally equal that of the lateral diameter (a ratio of 1:1). As the infant reaches toddlerhood, the anteroposterior diameter becomes less than the lateral diameter.

A 6-month-old infant is brought to the clinic. The mother reports the infant has been lethargic and not eating well. The infant's anterior fontanel is sunken. Which additional information is a priority for the nurse to assess? Skin color and cap refill Number of wet diapers the in the last 24 hours Number of feeds in the last 24 hours Number of hours infant has slept in the last 24 hours

Number of wet diapers the in the last 24 hours A sunken fontanel indicates dehydration. The nurse should assess the number of wet diapers the infant has had in the past 24 hours. This helps to determine the severity of the dehydration. Knowing the amount of fluid intake for 24 hours also helps assess the severity of the dehydration. If the baby is bottle fed the mother could give a specific amount. If breast fed the nurse would want to know how many times fed and for how long each time. Just knowing the number of feeds in 24 hours will not give accurate information to determine dehydration status. The number of normal hours slept at this age is variable and could be misleading without normal context for this infant. As well, lethargy with a sunken fontanel is related to dehydration as opposed to a neurological issue. Skin color and capillary refill assessment could indicate a perfusion problem.

An older infant who has been injured in an automobile accident is to wear a splint on the injured leg. The mother reports that the infant has become mobile even while wearing the splint. What should the nurse advise the mother to do? Keep the infant in the splint at night, removing it during the day. Notify the health care provider (HCP) immediately to adjust the treatment plan. Confine the infant to one room in the apartment. Remove any unsafe items from the area in which the infant is mobile.

Remove any unsafe items from the area in which the infant is mobile. Safety is the priority in caring for this infant. Infants adapt easily, increasing mobility even with a splint in place. Therefore, the mother needs to ensure that the area in which the infant is mobile is safe. There is no need to contact the HCP to alter the treatment plan. Confining the infant to one room may not allow the child to achieve normal development. The child needs different environments for maximum development. The infant needs to wear the splint as prescribed by the HCP to ensure optimal healing.

Two parents who are arguing in their infant's room, with voices raised and getting louder, start to hit each other. The infant is crying. Which action should the staff nurse take next? Remove the infant from the room. Try to reason with both of the parents. Call security to come and break up the fight. Ask one of the parents to leave the room.

Remove the infant from the room. The situation is escalating, and the nurse's priority is to protect the infant from harm. Therefore, removal of the infant from this situation should be the first action by the nurse, as long as doing so does not place the nurse at risk. Reasoning at this point or asking one of the parents to leave the room would likely be ineffective and may further escalate the situation. Calling security is necessary, but only after the nurse has removed the infant from the room.

The mother of an infant with hemophilia tells the nurse that she is planning to do home teaching when the child reaches school age. She does not want her child in school because the teacher will not watch the child as well as she would. The mother's comments represent what common parental reaction to a child's chronic illness? devotion insecurity mistrust overprotection

overprotection Overprotection is a typical parental reaction to chronic illness in a child. Characteristics include sacrifice of self and family for the child, failure to recognize the child's capabilities and sense of responsibility, placement of overly stringent restrictions on play and peer friendship, and a lack of confidence in other peoples' capabilities.

The nurse is treating an 8-month-old infant with scabies. What medication would the nurse prepare to administer for this infant? permethrin griseofulvin thiabendazole tolnaftate

permethrin Permethrin, supplied in a cream, is the treatment of choice for children younger than age 1. However, its safety hasn't been established for clients younger than 2 months. Griseofulvin and tolnaftate are used to treat ringworm, not scabies. Thiabendazole is used to treat hookworm, roundworm, threadworm, and whipworm.

A 10-month-old child with phenylketonuria (PKU) is being weaned from breast-feeding. When teaching the parents about the proper diet for their child, the nurse should stress the importance of restricting meats and dairy products because: they contain high levels of phenylalanine. they contain high levels of phenylketones, which inhibit muscle growth. they are difficult for clients with PKU to digest. they are not well tolerated in children with PKU until after age 2.

they contain high levels of phenylalanine. PKU is an inherited disorder characterized by the inability to metabolize phenylalanine, an essential amino acid. Phenylalanine accumulation in the blood results in central nervous system damage and progressive intellectual disability. However, early detection of PKU and dietary restriction of phenylalanine can prevent disease progression. Intake of high-protein foods, such as meats and dairy products, must be restricted throughout life because they contain large amounts of phenylalanine.

A 9-month-old is admitted because of dehydration. How should the nurse go about accurately monitoring fluid intake and output? Select all that apply. obtaining an accurate daily weight restricting fluids prior to weighing the child changing breast feedings to bottle-feedings weighing and recording all wet diapers obtaining an accurate stool count

weighing and recording all wet diapers obtaining an accurate stool count obtaining an accurate daily weight Accurate intake and output recording includes noting all intake, including intravenous fluids; noting output, such as emesis and stool; weighing diapers; measuring weight daily; measuring urine specific gravity; monitoring serum electrolytes; and monitoring for signs of dehydration. Children who are dehydrated must receive sufficient fluid intake, but having a breastfeeding child switch to bottle-feeding will not promote intake. Restricting fluids just prior to weighing the child will not alter the accuracy of the weight, and the nurse should continue to encourage fluids for this dehydrated child.

The nurse teaches the parent of an infant who has had a surgical repair for a cleft lip about the use of elbow restraints at home. The nurse determines that the teaching has been successful when the parent makes which statement? "After we get home, we will not have to use the restraints because our child does not suck on their hands or fingers." "We will keep the restraints on during the day while they are awake, but take them off when we put them to bed at night." "We will be sure to keep the restraints on all the time until we come to see the primary care provider for a follow-up visit." "We will only remove the restraints one at a time to check the skin under them for redness."

"We will only remove the restraints one at a time to check the skin under them for redness." To keep the infant from disturbing the suture line by placing fingers or other objects in the mouth, either intentionally or accidentally, the restraints should be in place at all times. They should be removed for a short period, however, so that the underlying skin can be checked for any redness or breakdown. The best approach is to remove one restraint, complete the inspection, and reapply before checking the other arm. While the restraints are removed, the parents should be instructed to manually restrain the hands and arms.