infants
The parent of a 4-year-old child asks about dental care for their child. "I help brush their teeth every day, and their teeth look healthy," the parent states. "When should I take them to see a dentist?" Which response would be most appropriate?
"A dental checkup is recommended even if no problems are noticeable."
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."
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 the health care provider find a mass in the abdominal area?"
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?
"Do you give the baby a bottle to take to bed?"
The parent of a toddler who has just been admitted with severe dehydration secondary to gastroenteritis says that they cannot stay with their child because they have to take care of their other children at home. Which of the responses by the nurse would be most appropriate?
"I understand, but feel free to visit or call anytime to see how your child is doing."
A nurse is teaching the parents of an infant with heart failure about the administration of furosemide. The parents will be administering the medication to the infant at home. What is the most important information for the nurse to teach the parents about the drug administration?
"It's important to call the clinic if there is no urine output in 8 hours."
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 their 6-month immunizations. The parent asks the nurse if the child will receive them. What is the nurse's best response?
"Make an appointment to come back to get your child's immunizations when they've finished the antibiotics."
The nurse interviews a preschool-age child who has been sexually abused about the event. Which approach would be most effective?
"Play out" the event using anatomically correct dolls.
The nurse is teaching a health promotion class to new parents about sudden unexpected infant death (SUID). What information would be most important for the nurse to teach?
"Prevention includes placing the infant supine on a firm sleeping surface."
A nurse in a clinic finds the parent of a 15-month-old child in tears. The parent states that their child doesn't love them, because the child says "no" to everything. Which response is appropriate?
"Saying 'no' is part of toddler development and is normal at this age."
A parent expresses concern because their 3-year-old child frequently fondles their penis. The parent does not know the best approach for the child's behavior. What is the nurse's best response to the parent?
"This behavior is normal for a child of their age."
A parent asks the nurse about the nutritional needs of their toddler. Which response by the nurse would be most appropriate?
"Toddlers have definite food preferences."
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 birth parent asks if they can try to breastfeed the infant. What is the nurse's best response?
"Until assessments are complete, we should not give your child anything by mouth."
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.
8.2
The nurse meets with the family of a 3-year-old child who is seriously ill. What is the most important role of the nurse as collaborator?
Coordinates the multidisciplinary services and provides information about them.
Which action should the nurse include when developing the plan of care for a neonate before surgical repair of a myelomeningocele?
Covering the defect with moist, sterile saline dressings
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?
Document this finding as on the high end of the normal range and plan to reassess.
Which action should the nurse take when suspecting that a child has been abused by the parent?
Ensure that any and all findings are reported to the proper authorities.
Assessment of a 6-week-old infant reveals a weight and length in the 50th percentile for age and a head circumference at the 95th percentile. What should the nurse do first?
Examine the fontanels and sutures.
The nurse develops the preoperative teaching plan for a 14-month-old child with an undescended testis who is scheduled to have surgery. Which method is most appropriate?
Explain to the parents how the defect will be corrected.
The nurse is teaching the parents of an 8-month-old about what the child should eat. The nurse should include which information points in the teaching plan?
Formula can be changed to whole milk when the infant is 12 months old.
A nurse is preparing to administer an IV containing dextrose 10% in ¼ normal saline solution to a 6-month-old infant. The nurse should select which tubing to safely administer the solution?
IV tubing with a volume-control chamber
Which serum electrolytes findings should the nurse expect to find in an infant with persistent vomiting?
K+, 3.2; Cl-, 92; Na+, 120
A child is being discharged after being diagnosed with an asthma attack. What information regarding the rescue inhaler is most important for the nurse to include in discharge teaching?
Monitor heart rate.
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.
An infant underwent surgery to remove a myelomeningocele. The infant has bulging fontanels. Which is the nurse's best action?
Notify the health care provider.
A nurse is caring for an infant being treated for an upper respiratory infection. The health care provider would like to order a series of X-rays for the infant, who has been in a foster home for 4 months. How should the nurse obtain consent?
Obtain consent from the foster parents.
The nurse is caring for a hospitalized toddler who is having a temper tantrum. What is the most realistic approach for the nurse to use to manage the child's temper tantrum?
Offer disapproval and then ignore the tantrum.
A preschool child immobilized in a hip spica cast has trouble breathing after meals. Which action would be best for the nurse to take?
Offer the child small feedings several times a day.
After assessing a newly admitted 5-year-old child, the nurse makes the nursing diagnosis of parental role conflict related to child's hospitalization. Which defining characteristic suggests this diagnosis?
Parents express feelings of inadequacy in caring for child.
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?
Perform a neurologic assessment.
A 23-month-old child pulls a pan of hot water off the stove and spills it onto their chest and arms. Their parent is right there when it happens. What should the parent do immediately?
Place the child in a bathtub of cool water.
A 911 call was received from a parent indicating their infant is not breathing. Police officers, emergency medical technicians (EMTs), and paramedics arrived at the scene first, resuscitation was unsuccessful. Coroner was called to parents' home to examine infant to determine cause of death. Public health nurses were called to provide support to family. Infant was found in their crib lying on their back; crib had a well-fitting mattress, tight sheets, no blankets or toys, and was up against the back wall of parents' bedroom away from curtains or blinds. Parents deny any gastrointestinal or respiratory infections since birth; they state their infant seemed healthy when they put them to bed last night around 9 p.m.
Potential Conditions sudden infant death syndrome (SIDS) Actions to Take Offer to call clergy. Anticipate an autopsy. Parameters to Monitor status of autopsy report parents' emotions
The nurse is caring for a 16-heur-old newborn infant in the nursery. 0730 Female newborn delivered by spontaneous vaginal delivery weighing 7 lbs. (3.2 kg). Agars 8, 9. Uncomplicated, term pregnancy.
Potential complication Bilirubin encephalopathy Possible actions Notify the blood bank of the need for an exchange transfusion. Obtain a phototherapy wrap unit. Parameters to monitor Newborn reflexes Serum bilirubin
A nurse is performing a neurologic assessment on an infant. When assessing for function of cranial nerve X (vagus), which technique is most appropriate to use?
Press a tongue blade on the posterior surface of the tongue.
The nurse develops the teaching plan for the parents of a 12-month-old infant with hypospadias and chordee repair. What information is most important to include?
Prevent the child from disrupting the catheters by using soft restraints if needed.
Which instruction would be most appropriate for the nurse to include in the teaching plan for the parent of a 1-year-old child who is to receive iron therapy with ferrous sulfate drops?
Put the drops in the child's mouth, and then follow with juice.
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?
Sew thick padding into the elbows and knees of the child's clothing.
A parent brings a 2-month-old infant to the clinic for a well-baby checkup. To best assess the interaction between the parent and infant, the nurse should observe them:
as the parent feeds the infant.
A toddler with a ventricular septal defect is receiving digoxin to treat heart failure. Which assessment finding should be the nurse's priority concern?
bradycardia
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?
burping the infant during and after the feeding
A parent brings a 4-month-old to the clinic for a regular well visit and expresses concern that the infant is not developing appropriately. Which finding in the infant would indicate the need for further developmental screening?
does not babble
The nurse observes a parent instilling ear drops prescribed twice a day for a 2-year-old. The nurse decides that the teaching about positioning the pinna for instillation of the drops is effective when the parent pulls the toddler's pinna in which direction?
down and backward
The health care provider suspects tracheoesophageal fistula in a 1-day-old neonate. Which nursing intervention is most appropriate for this child?
elevating the neonate's head and giving nothing by mouth
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.
The nurse teaches the parents of a neonate who has undergone corrective surgery for tracheoesophageal fistula about the need for ongoing health care. The nurse bases the teaching on the child's high risk for which condition?
esophageal stricture
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?
excessive cerebrospinal fluid within the cranial cavity
On a home visit following discharge from the hospital after treatment for severe gastroenteritis, the parent tells the nurse that a toddler answers "No!" and is difficult to manage. After discussing this further with the parent, the nurse explains that the child's behavior is most likely the result of which factor?
expression of individuality
The nurse is assessing a 2-year-old child's development. What assessment finding would warrant further investigation by the nurse?
having a vocabulary of 100 words
A preschool-age child scheduled for surgery in the morning is admitted to the facility for the first time. Which nursing action would ease the child's anxiety?
having the child act out the surgical experience using dolls and medical equipment
After surgery to repair a cleft lip, an infant has a Logan bow in place. Which postoperative nursing action is appropriate?
holding the infant semi-upright during feedings
The nurse is caring for a child in the early stages of burn recovery. Which nursing diagnosis does the nurse prioritize?
impaired skin integrity
When assessing a family suspected of abusing its 4-year-old child, which behavior is the most important criterion that would suggest abuse?
incompatibility between the history (mechanism) and the injury
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?
ineffective airway clearance
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?
intermittent with knees drawn to the chest
The nurse performs a well-child checkup on a 2-year-old at the clinic. Which skill should the nurse expect the child to be able to perform?
kicking a ball forward
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?
knee-to-chest
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?
lumbar puncture
An infant is hospitalized for treatment of inorganic failure to thrive. Which nursing action is most appropriate for this child?
maintaining a consistent, structured environment
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?
nipple
While examining a 2-year-old client, the nurse sees that the anterior fontanel is open. The nurse should
notify the health care provider.
An infant requires tracheal suctioning after the nurse assesses airway congestion. Which is the priority initial action when performing the procedure?
oxygenation prior to the procedure
The parent of a child with tetralogy of Fallot asks the nurse why the child has clubbed fingers. The nurse bases the response on the understanding that clubbing is due to which factor?
peripheral hypoxia
A nurse is obtaining the history of an infant with suspected acute otitis media. What should the nurse ask the parent about?
position of the infant when taking a bottle
The nurse prepares to admit an infant diagnosed with diarrhea to the pediatric unit. Which room should the nurse assign the infant to?
private room
The parent of a toddler diagnosed with iron deficiency anemia asks what foods they should give their child. The nurse should evaluate the teaching as successful when the parent later reports that they feed the toddler which foods?
raisins, chicken, and spinach
A 4-year-old child is admitted to the hospital for surgery. The nurse applies interventions to address what major stressor for a child of this age?
separation from family
Which of the following objects poses the most serious safety threat to a 2-year-old client in the hospital?
side rails in the halfway position
What liquid does the nurse recommend the parents of a 1½-month-old infant with hypothyroidism use to administer levothyroxine with?
small amount of formula or breast milk
The nurse gives anticipatory guidance to the parents of a 5-month-old infant about toy safety. What toys should the nurse recommend?
soft, washable toys
Which finding indicates that the infant has adequately evacuated the barium after undergoing a barium enema?
stools that progress from clay-colored to brown
In which parts of the body should the nurse administer an intramuscular injection to a 6-month-old infant?
the lateral middle third of the thigh between the greater trochanter and the knee
The nurse has a prescription to administer an IM injection to a neonate. Which injection site should the nurse select?
vastus lateralis
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?
weekly visits by a community health nurse
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?"
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
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
Eight hours ago, an infant with Hirschsprung disease had surgery to create a colostomy. Which finding should alert the nurse to notify the health care provider (HCP) immediately?
3-cm increase in abdominal circumference
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 back blows.
The nurse is caring for an infant diagnosed with thrush. Which instruction would the nurse give to a client's parent who will be administering nystatin oral solution?
Administer the drug right after meals by dabbing the solution to the sites.
The parent of an 11-month-old infant reports to the nurse that the infant sleeps much less than other children. The parent asks the nurse whether the infant is getting sufficient sleep. What should be the nurse's initial response?
Ask the parent for more information about the infant's sleep patterns.
A parent brings an infant to the health clinic for a well-baby checkup. During the assessment, the nurse measures the head circumference of the child and notes that there has been a rapid increase in size. What action should the nurse take next?
Assess for signs of increased intracranial pressure.
A 2-month-old male infant is admitted to the inpatient pediatric unit for treatment of pneumonia. Infant's maternal parent notes that the infant is breastfeeding and taking breast milk by bottle approximately every 4 hours. Infant's birth parent notes that infant breastfed at 0600 and has had a wet diaper this morning. Birth parent states that they will need to be at home for a few hours, but that they will leave a bottle for the 1000 feeding.
At 1000, the nurse should first raise the infant's head and shoulders and turn the head to one side and then slide the syringe into the infant's mouth along the tongue to release the drug
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.
When teaching a group of parents about the potential for febrile seizures in children, which information should the nurse include?
The seizures occur as the fever rises.
When developing a teaching plan for parents of toddlers about poisonous substances, the nurse should emphasize which safety points? Select all that apply.
Toddlers should be adequately supervised at all times. All poisonous substances should be kept out of the reach of children and stored in a locked cabinet if necessary. The difference between pediatric and adult dosages of medicines is significant, and adult dosages given to children can have serious, harmful effects. Following any poisoning, the parents should call the Poison Control Center for instructions for appropriate treatment.
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?
Use a bulb syringe to suction out the nasal passages.
A 10-month-old child has cold symptoms. The birth parent asks how they can clear the infant's nose. What would be the nurse's best recommendation?
Use saline nose drops and then a bulb syringe.
A toddler diagnosed with nephrotic syndrome has a fluid volume excess related to fluid accumulation in the tissues. Which measure should the nurse anticipate including in the child's plan of care?
Weigh the child before breakfast.
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.
A registered nurse (RN) has been paired with a licensed practical nurse (LPN) for the shift. Whose care should the RN delegate to the LPN?
a 2-year-old child who nearly drowned 2 days earlier
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?
a 3-cm increase in abdominal circumference
A young child is returning to the pediatric unit after having surgery to form a colostomy. When assessing the stoma, the nurse becomes most concerned when what is observed?
a dark maroon stoma
Which information obtained during the nursing history would help support a child's diagnosis of hemophilia?
a maternal uncle with prolonged postoperative bleeding
The parent 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 interpret this finding?
a positive Babinski sign
A 2-year-old child always puts their teddy bear at the head of the bed before they go to sleep. The parents ask the nurse if this behavior is normal. The nurse should explain to the parents that toddlers use ritualistic patterns to establish which factor?
a sense of security
An infant has just had surgery to repair a cleft lip. Which nursing intervention is most important during the immediate postoperative period?
cleaning the suture line carefully with a sterile solution after every feeding
The nurse is caring for a child whose parent is deaf and untrusting of staff. They frequently cry at the bedside, but refuses intervention from the social worker or the chaplain. Which issue is most important for the nurse to address with the parent to promote a trusting relationship?
communication barriers between the parent and staff
Which nursing activity supports the principles of palliative care for a dying infant and the infant's family?
creating a therapeutic, homelike environment for the infant and the infant's family
