Infant Prep U
A nurse is teaching the mother of an infant. The nurse should instruct the mother to introduce her infant to solid foods at what age?
6 months Rationale: Solid foods are typically introduced around age 6 months. They aren't recommended at an earlier age because of the protrusion and sucking reflexes and the immaturity of the infant's GI tract and immune system. By age 8 months, the infant usually has been introduced to iron-fortified infant cereal and vegetables and will begin to try fruits.
Before a routine checkup, an 8-month-old infant sits contentedly on the mother's lap, chewing on a toy. When preparing to examine this infant, what should the nurse plan to do first?
Auscultate the heart and lungs. Rationale: The nurse should first ausculate 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 him may cause distress, making the rest of the examination more difficult.
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. Rationale: 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.
Which of the following instructions 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. Rationale: 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 primary health care provider 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.
Laboratory results for a child with a congenital heart defect with decreased pulmonary blood flow reveal an elevated hemoglobin (Hb) level, hematocrit (HCT), and red blood cell (RBC) count. These data suggest which condition?
Compensation for hypoxia Rationale: A congenital heart defect with decreased pulmonary blood flow alters blood flow through the heart and lungs, resulting in hypoxia. To compensate, the body increases the oxygen-carrying capacity of RBCs by increasing RBC production, which causes the Hb level and Hct to rise. In anemia, the Hb level and Hct typically decrease. Altered electrolyte levels and other laboratory values are better indicators of dehydration. An elevated Hb level and HCT aren't associated with jaundice.
An infant diagnosed with Hirschsprung's disease is scheduled to receive a temporary colostomy. When initially discussing the diagnosis and treatment with the parents, which of the following would be most appropriate?
Encouraging them to ask questions. Rationale: By encouraging parents to ask questions during information-sharing sessions, the nurse can clarify misconceptions and determine the parents' understanding of information. A better understanding of what is happening allows the parents to feel some control over the situation. Assessing the adequacy of the parents' coping skills is important but secondary to encouraging them to express their concerns. The questions they ask and their interactions with the nurse may provide clues to the adequacy of their coping skills. The nurse should never give false reassurance to parents. At this point, there is no way for the nurse to know whether the child will be fine. Written materials are appropriate for augmenting the nurse's verbal communication. However, these are secondary to encouraging questions.
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 of the following is the appropriate action by the nurse?
Explaining to the client that this reflex disappears around 3-4 months Rationale: 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 mother 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.
A nurse should assess the maturity of enzyme systems (kidney and liver) in which pediatric population before administering medications?
Premature infants Rationale: 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.
An infant with increased intracranial pressure (ICP) on a regular diet vomits while eating dinner. Which of the following should the nurse do next?
Wait a few minutes, then refeed the child. Rationale: Increased ICP can cause vomiting, particularly in children whose fontanels are closed. An infant with an open anterior fontanel may have less vomiting because the cranium can respond, expanding with increased ICP. The best course of action is to wait a few minutes and then refeed the child. Putting the child on NPO status may not be helpful because this is not a gastrointestinal problem. Because this is an expected event, notifying the physician is not necessary. Antiemetics frequently make a client sleepy, making neurologic checks difficult to interpret.
When an infant with pyloric stenosis is admitted to the hospital, which of the following should the nurse do first?
Weigh the infant. Rationale: Unless the infant is in hypovolemic shock, obtaining a baseline weight is an important first action because the weight is used to calculate the child's fluid and electrolyte needs. The intravenous fluid rate and the amounts of electrolytes to be added to the fluid are based on the infant's weight. The weight also helps determine the infant's degree of dehydration. The intravenous infusion is initiated once the weight has been obtained. The child with pyloric stenosis typically experiences vomiting and is at risk for fluid volume deficit and metabolic acidosis. As a result, oral food and fluids are withheld and the infant is allowed nothing by mouth. Fluid replacement is given intravenously. Orientation can wait until treatment is under way.
The nurse is assessing a 10-month-old infant during a checkup. Which developmental milestones would the nurse expect the infant to display? Select all that apply.
• Holding head erect • Sitting on a firm surface without support • Bearing majority of weight on legs Rationale: By age 3 months, an infant should be able to hold the head erect. By age 10 months, he or she should be able to sit on a firm surface without support and bear most weight on the legs (for example, walking while holding on to furniture). Self-feeding and bowel and bladder control are developmental milestones of toddlers. By age 12 months, the infant should be able to stand alone and may take first steps.
The father of a 3-week-old infant who has developed sepsis says that he feels guilty because he did not realize his infant was sick. Which of the following responses by the nurse would be most appropriate?
"Babies can get sick quickly, and parents do not always realize it." Rationale: The signs and symptoms of sepsis in a neonate, such as changes in appearance and behavior, are almost imperceptible. Often, the parents' only concern is that the neonate does not look "right." Fever and localized response, which are clues to infections in older children, are often absent in the neonate. Telling the father that he should have realized something was wrong is condescending and serves only to further the father's guilt feelings. Asking the father whether he read the booklet from the hospital implies that the father is at fault. One experience would not necessarily ensure that the father would be able to detect sepsis another time.
A 6-month-old infant has a high fever and cold symptoms. She is pulling at her left ear. She is scheduled to receive her 6-month immunizations. The mother asks the nurse if she will receive them. The nurse's best response would be:
"She can have them when she returns to have her ear rechecked." Rationale: Generally, immunizations are not given to a child with a severe febrile illness. Once the child is well, then normal immunizations can be given. The child does not need to wait 6 months. The immunization schedule will be resumed when the child is well. Pneumococcal vaccines are not given until the child is 2 years old.
An infant was taken from the ward by its parents without the knowledge of the nurses on the ward. The charge nurse conducts a performance improvement process to determine which of the following statements?
Conducting a root cause analysis. Rationale: Root cause analysis is used to gather information about factors that contribute to a problem (root causes) so that the nurse can identify ways to correct the problem. Random observation doesn't necessarily produce data to explain a specific sentinel event. Evaluation of a single incident rarely identifies underlying causes and contributing factors to sentinel events. An expert consultation doesn't necessarily reveal site-specific underlying causes and contributing factors in an individual health care facility.
When positioning a neonate with an unrepaired myelomeningocele, which of the following positions is most appropriate?
Prone with hips in abduction. Rationale: 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's position, even though the chest and abdomen are elevated.
The health care team wishes to establish a policy regarding sleep positions for infants with gastroesophageal reflux disease (GERD). The first step should be to search for:
Published national standards. Rationale: 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.
The nurse is discharging a baby with clubfoot who has had a cast applied. The nurse should provide additional teaching to the parents if they state:
"I should use a pillow to elevate my child's foot as he sleeps." Rationale: 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 of 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 5-10 casts to correct the deformity. Infants with club feet still need frequent holding like any other newborn.
A 6-month-old on the pediatric floor has a respiratory rate of 68, mild intercostal retractions, and an oxygen saturation of 89%. The infant has not been feeding well for the last 24 hours and is restless. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the primary healthcare provider with the recommendation for:
Starting oxygen. Rationale: The infant is experiencing signs and symptoms of respiratory distress indicating a need for oxygen therapy. Sedation will not improve the infant's respiratory distress and would likely cause further respiratory depression. If respiratory status continues to decline, the infant may need to be transferred to the PICU. Oxygen should be the priority, because it may improve the infant's respiratory status. A chest CT is not indicated; however, a chest x-ray would be another appropriate recommendation for this infant.
