question

What factor is most significant for the nurse working with the family of an infant born with a genetic disorder.

answer

the family's readiness to talk about problems their infant may have in the future

question

A nurse in the pediatric clinic receives a call from the mother of a 12-month-old infant who has had a fever, runny nose, cough, and white spots in the mouth for 3 days. A rash started on the face and has now spread to the entire body. Which communicable infection does the nurse suspect?

answer

Rubeola

question

A nurse is assessing the growth and development of a 6-month-old infant. What behavior indicates that the infant has reached the expected level of development?

answer

holds a bottle without help

question

A 3-week-old infant is admitted with a tentative diagnosis of hypertrophic pyloric stenosis. Before conducting the admission assessment of the abdomen, the nurse moves the infant's legs in a bicycling-type motion. How does this help the nurse's assessment?

answer

relaxes abdominal muscles

question

A nurse is assessing the development of an 8-month-old infant. Which behaviors are expected at this stage of development? Select all that apply.

answer

-creeping purposefully -displaying a pincer grasp

question

The nurse is caring for a group of patients who require various interventions. What patient care may be delegated to unlicensed assistive personnel (UAP)?

answer

bathing a child with an intravenous line and a patent-controlled analgesia (PCA) pump

question

An infant with a cleft lip is fed with a special nipple. What should the nurse teach the parents about feeding their infant to minimize regurgitation?

answer

Burp frequently during a feeding.

question

What does a nurse recognize as the most serious complication of meningitis in young children?

answer

Peripheral circulatory collapse

question

The parents of an infant who has undergone surgical repair of a myelomeningocele express concern about skin care and ask what they can do to prevent problems. What should the nurse teach the parents about their infant's skin care?

answer

Will require long-term care multidisciplinary follow up care

question

At 5 minutes after birth a neonate's heart rate is 120 beats/min, the cry is weak, the body color is pink, the extremities are flexed with brisk movement, and the neonate grimaces when stimulated. What is the neonate's Apgar score?

answer

8

question

A nurse inserts a nasogastric tube before an infant is to receive a tube feeding. What action should the nurse take when the infant begins to cough and gag?

answer

Removeing the tube, then reinserting it

question

A nurse suspects that a 7-month-old infant who is brought to the well-baby clinic for the first time has a hearing deficit. What behavior leads the nurse to come to this conclusion?

answer

The mother says that the infant stopped making verbal sounds about a month ago

question

Which behavior does the nurse expect when observing a 5-month-old infant?

answer

Picking up a toy and putting it in the mouth

question

The preoperative nurse is reviewing a child's history and physical before repair of a ventricular septal defect. Which assessment finding should the nurse expect?

answer

bilateral lung sounds with rales and rhonchi

question

The hypertonicity of the muscles in an infant with cerebral palsy causes scissoring of the legs. The nurse teaches the mother that the preferred way to carry the infant is in a sitting position in what way?

answer

Astride one of her hips

question

A nurse is concerned about helping the parents of an infant with cerebral palsy set long-term goals for the family. What is most important to understand when setting long-term goals?

answer

unknown extent of the disability requires continual adjustments

question

The parents of an infant with uncorrected Hirschsprung disease are advised to give their child low-residue diet. What choice indicates that the parents need further teaching about the diet?

answer

apples

question

The mother of an infant with meningitis is concerned that if she stays with her infant at the hospital her toddler at home will feel neglected. How should the nurse respond?

answer

"can you arrange with someone to stay here when you are at home?"

question

The nurse observes that an infant has head control and can roll over but can neither sit up without support nor transfer an object from one hand to the other. What developmental age should the nurse estimate on the basis of these observations?

answer

5 to 6 months

question

A 9-month-old infant is admitted to the pediatric unit with a possible head injury. Twelve hours later the nurse determines that the previous blood pressures were taken using a neonate-size cuff. The nurse documents the size of the cuff that was used for previous measurements. What is the best action for the nurse to take?

answer

Taking the next measurement with both a neonate- and a child-size cuff

question

A 4-week-old infant is admitted to the pediatric unit for cleft lip repair. The nursing assistant asks the nurse why the repair is being done at this age. What is the best response the nurse can give as to why cleft lip repair is performed so soon?

answer

Has an emotional effect on the parents

question

A nurse is teaching a class about behavioral expectations of infants and children to a group of parents. What does the nurse include as behaviors expected of 8-month-old infants? Select all that apply.

answer

-stranger anxiety -playing peek-a-boo -standing by holding on to furniture

question

A new father tells a nurse that his sister and her family plan to visit the new baby and that his niece and nephew have just recovered from chickenpox (varicella). Their lesions are completely healed or have scabs and are no longer draining. He asks the nurse whether it is safe for them to be near the baby. What is the best response by the nurse?

answer

"The most contagious time is before the spots appear. It'll be safe to visit."

question

Six weeks after birth an infant is found to have developmental dysplasia of the hip. The nurse explains to the parents the benefits of early treatment. What is the rationale for the immediate institution of corrective measures?

answer

Infants' cartilaginous hip joints promote molding of the acetabulum.

question

A 6-week-old infant has just been found to have gastroesophageal reflux. What teaching is most important to discuss with the parents at this time?

answer

providing formula thickened with cereal

question

An infant is admitted to the pediatric unit with bronchiolitis caused by respiratory syncytial virus (RSV). What interventions are appropriate nursing care for the infant? Select all that apply.

answer

-instilling saline nose drops -maintaining contact precautions -suctioning mucus with a bulb syringe

question

What should the plan of care for a newborn with hypospadias include?

answer

Giving the parents reasons why circumcision should not be performed

question

An infant who has undergone surgical correction of a myelomeningocele is to be discharged. What information should the nurse include when preparing the parents to care for their infant at home?

answer

How to perform range-of-motion exercises for the lower extremities

question

The parents of an infant with tetralogy of Fallot ask the nurse to explain what is wrong with their baby's heart. Before explaining the problem in a way that they will understand, the nurse remembers that tetralogy of Fallot includes what features?

answer

Right ventricular hypertrophy, ventricular septal defect, pulmonic stenosis, and overriding of the aorta

question

An infant is admitted to the pediatric unit with gastroenteritis and dehydration. The nurse determines that the parents understand the teaching about contact precautions when they note that after washing their hands they need to do what?

answer

Change their gloves each time they change the baby's diaper.

question

A nurse is discussing an infant's diet with a mother who is breastfeeding. Why should the nurse recommend that the infant be offered solid foods by 5 or 6 months of age? Select all that apply.

answer

-fetal iron resereves are depleted -food can be taken from a spoon

question

One minute after birth a neonate's heart rate is 106 beats/min; acrocyanosis and muscle tone with flexion are observed; flicking the sole triggers crying, and the cry is strong. What is the neonate's Apgar score?

answer

9

question

A nurse is assessing a 6-month-old infant's motor skills. Which skills does the nurse expect this infant to exhibit? Select all that apply.

answer

-bears weight on hands when prone -turns from prone to supine position at will

question

The mother of a 3-month-old infant asks the nurse in the well-baby clinic what toys to give her child. What is the nurse's response? Select all that apply.

answer

-metallic mirror -colorful mobile

question

What fact about eczema should a nurse discuss with the parents of a child in whom the condition has just been diagnosed?

answer

-it is mainly found in infants

question

An infant born with exstrophy of the bladder is admitted to the pediatric unit for urinary diversion surgery in which the ureters are to be transplanted to a resected section of the small intestines, with one end attached to the abdominal wall. What does the nurse call the procedure when explaining the surgery to the parents?

answer

ileal conduit

question

A nurse is assessing a 1-month-old infant with suspected hypertrophic pyloric stenosis (HPS). Referring to the figure, in what area should the nurse expect to palpate an olive-shaped mass?

answer

D

question

A 1-month-old infant is admitted to the pediatric unit with a tentative diagnosis of Hirschsprung disease (congenital aganglionic megacolon). What procedure does the nurse expect to be used to confirm the diagnosis?

answer

rectal biopsy

question

An infant with a cleft lip and palate is admitted to the hospital for surgical repair. Place the nurse's postoperative interventions in order of priority.

answer

1. maintaining a patent airway 2. preventing vomiting 3. monitoring parenteral fluid infusions 4.teaching the parents alternate feeding methods 5. Assessing the infant's hearing status

question

A nurse is caring for an infant who just underwent surgery for a cleft lip. In which position should the nurse place the infant?

answer

low fowler

question

A nurse is caring for an infant with bilateral cryptorchidism. While clarifying the need for surgery with the parents, what information does the nurse communicate regarding the child's prognosis if the problem is not corrected?

answer

sterility upon maturity

question

A 6-week-old infant and his mother arrive in the emergency department in an ambulance. The father arrives several minutes later with two children, 7 and 9 years old. The infant is not breathing, and the eventual diagnosis is sudden infant death syndrome (SIDS). The parents take turns holding the infant in another room. The nurse remains present and provides emotional support to the parents. What is an important short-term goal for this family?

answer

Including the infant's siblings in the events and grieving in the wake of the infant's death

question

An infant is found to have cerebral palsy (CP) several months after birth. When the infant is 10 months old the mother comes to the pediatric clinic because the child has begun to exhibit slow writhing movements. The nurse explains that these movements are characteristically associated with what type of CP?

answer

Athetoid

question

Which item should a nurse use to feed an infant born with a unilateral cleft lip and palate?

answer

Rubber-tipped syringe

question

Which activities should the nurse expect to see exhibited by a healthy 6-month-old infant during an evaluation of the infant's growth and development? Select all that apply.

answer

-playing peek-a-boo -turning completely over -reaching to be picked up -sitting for a short time without support

question

An infant who has a congenital heart defect with left-to-right shunting of blood is admitted to the pediatric unit. What early sign of heart failure should the nurse identify?

answer

-increased respiratory rate

question

A 12-month-old infant has become immunosuppressed during a course of chemotherapy. What information regarding the measles, mumps, and rubella (MMR) vaccine should the nurse, preparing for the infant's discharge, give the parents?

answer

infants who are receiving chemotherapy should not be given these vaccines

question

The mother of an 11-month-old infant who just underwent surgery to create a temporary colostomy is concerned about care at home. What instructions about care of the colostomy should the nurse include in the teaching plan?

answer

Empty and rinse the bag whenever necessary

question

A nurse is caring for an infant with severe dehydration. Which blood gas report most likely reflects the acid-base balance of this infant?

answer

pH of 7.20 and HCO3- of 20 mEq/L (20 mmol/L)

question

A neonate with an imperforate anus undergoes a colostomy. In which positions should the nurse place the infant during the postoperative period? Select all that apply.

answer

-supine with head of crib elevated -side-lying with head of crib elevated

question

An infant who had been receiving humidified oxygen because of dyspnea caused by acute spasmodic laryngitis is being discharged. The parents ask the nurse about caring for their baby at home. What is the best response by the nurse?

answer

"There are no restrictions after your baby goes home."

question

After an infant who was born with talipes equinovarus (clubfoot) has the cast removed, the nurse teaches the mother how and when to exercise the baby's foot. The nurse concludes that the mother understands the instructions when she says that she will exercise the foot with what frequency?

answer

with each diaper change

question

A nurse administers the first series of immunizations to a 2-month-old infant. The nurse tells the mother that if the site becomes inflamed, she should give the prescribed acetaminophen (Tylenol). What else should the nurse instruct the mother to do?

answer

place a warm compress on the area

question

A nurse is caring for an infant who has undergone surgery to repair a diaphragmatic hernia. What is the best position for the nurse to place the infant in?

answer

supine with the head of the bed elevated

question

A 5-month-old child undergoes heart surgery to repair the defects associated with tetralogy of Fallot. Prevention of what behavior is a priority for the nurse after the surgery?

answer

straining at stool

question

While discussing immunizations with the nurse, the parent of a 7-month-old boy states, "You know, my son doesn't sit up by himself yet. Shouldn't he be able to do this by now?" How should the nurse respond?

answer

"Many babies don't sit up until they're 8 months old. Let's watch what he does when I sit him up."

question

A nurse determines that no further health teaching is needed for the parents of a 6-month-old infant when they state that they will introduce new foods in the recommended order. List the order in which these new foods should be introduced.

answer

1. rice cereal 2. oatmeal cereal 3. mashed bananas 4. pureed beef 5. soft-boiled eggs

question

An infant has been admitted for dehydration as a result of acute gastroenteritis and vomiting, and the nurse administers lactated Ringer solution intravenously. The nurse concludes that the treatment has been effective after noting what?

answer

three wet diapers in 24 hours

question

Because of a measles epidemic, a 6-month-old infant receives measles immunoglobulin. The nurse should help the parents understand that to ensure continuous protection against measles, the infant should be revaccinated around what age?

answer

12 months

question

The nurse has taught newborn care and safety to a group of expectant mothers. Which statement by a mother indicates the need for additional teaching?

answer

"I'll keep my baby in a backward-facing car seat until he's a year old."

question

What nursing intervention best meets a major developmental need of a newborn in the immediate postoperative period?

answer

giving a pacifier to the infant

question

The condition of a child dying of leukemia deteriorates, and the child becomes comatose. The parents state that a relative told them that they should not allow the child to be resuscitated, but they are unsure. Which response by the nurse best demonstrates recognition of the ethical issues involved?

answer

"The final decision must be made by you and your doctor, but it's important to talk about it."

question

What dietary information should the nurse include in the teaching plan for parents of an infant with galactosemia? Select all that apply.

answer

-eliminate milk -provide soybean-based formulas

question

A ventroperitoneal shunt is inserted in a 4-month-old infant with hydrocephalus. Which signs of shunt failure should the nurse teach the parents during preparations for the infant's discharge? Select all that apply.

answer

-vomiting -distended fontanels

question

A 25-day-old infant is admitted to the hospital after 3 days of vomiting, and pyloric stenosis is diagnosed. What are the important nursing assessments at the time of admission? Select all that apply.

answer

-tissue turgor -neurologic status -amount of last voiding

question

At 20 hours of age a newborn is found to have a bilirubin concentration of 13 mg/dL (274 mcmol/L). Which finding most likely contributed to this bilirubin level?

answer

cephalhematoma

question

When assessing an infant's ability to sit without help, the nurse must know the developmental steps that preceded this accomplishment. Place these developmental steps in order, beginning with the one that occurs first and ending with the one that occurs last.

answer

1. gains head control 2. turns from the abdomen to the back 3. turns form the back to the abdomen 4. Sits alone in the tripod position 5. assumes the sitting position independently

question

A 6-month-old infant has a congenital right-to-left shunt defect of the heart. What clinical findings are expected when the nurse completes a history and physical assessment and reviews the child's laboratory reports? Select all that apply.

answer

-tissue hypoxia -increased hematocrit

question

A parent asks the nurse, "The doctor said my baby has something called pulmonic stenosis. What does that mean?" What is the best response by the nurse?

answer

-what else did the doctor say

question

A 5-week-old infant is admitted to the hospital with a tentative diagnosis of a congenital heart defect. The infant tires easily and has difficulty breathing and feeding. In what position should the nurse place this infant?

answer

side-lying, with the upper body elevated

question

A nurse teaches a parent about appropriate play for an 8-month-old infant. Which of the parent's suggestions indicate that the teaching has been understood? Select all that apply.

answer

- textured book - stuffed animal - hanging mobile

question

A nurse is planning to assess the vomitus of an infant with pyloric stenosis. Why does the nurse anticipate that the vomitus will be white rather than bile-stained?

answer

there is an obstruction above the opening of the common bile duct

question

An infant who was in a motor vehicle collision has undergone open repair of a fractured sternum and now has a chest tube. What should the nurse explain to the infant's parents about the chest tube?

answer

"the tube has been placed to drain the air that entered the chest cavity during surgery."

question

What intervention is included in the nursing care plan for a 4-month-old infant with tetralogy of Fallot and heart failure?

answer

providing small, frequent feedings

question

A 4-month-old infant is being treated for talipes equinovarus (clubfoot). The infant has a cast change every 2 to 3 weeks. When the infant is brought to the well-baby clinic for a routine visit, a nurse evaluates the foot in the cast. Which assessments should the nurse include? Select all that apply.

answer

-color of the toes on the foot in the cast -movement of the toes of the foot in the cast

question

An infant is receiving the first diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) at 2 months of age. What instructions should the nurse give the parents?

answer

Call the clinic if marked drowsiness occurs

question

The nurse is caring for a 12-month-old infant with a diagnosis of failure to thrive. The infant's weight is below the third percentile, and development is delayed. Which behaviors of the child suggest to the nurse the possibility of parental neglect? Select all that apply.

answer

- stiff - withdrawn - minimal smiling - little interest in the environment

question

A nurse is conducting a physical assessment of an infant with pyloric stenosis. What clinical findings does the nurse expect? Select all that apply.

answer

- visible peristaltic waves - olive-shaped mass in the right upper quadrant

question

A nurse is caring for a child with meningococcal meningitis. What clinical finding does the nurse expect to encounter during a physical assessment?

answer

purpuric skin rash

question

A prescription for an isotonic enema is written for a 2-year-old child. What is the maximal amount of fluid the nurse should administer without a specific prescription from the healthcare provider?

answer

255 to 360 mL

question

A nurse is caring for an infant after a cleft lip repair. Which item should the nurse use to feed the infant for several days after the surgery?

answer

rubber-tipped syringe

question

A 2-month-old infant is admitted to the pediatric unit with gastroenteritis and dehydration. Which assessment finding should the nurse anticipate?

answer

tachycardia

question

A nurse evaluating a 1-year-old infant's hematocrit reading compares it with the expected hematocrit range for this age group. What is the hematocrit of a healthy 12-month-old infant?

answer

29% to 41%

question

A 6-month-old infant is to be on nothing-by-mouth (NPO) status for 4 hours before surgery for cleft palate repair. What is the most important concern for the infant before surgery?

answer

Altered fluid intake before surgery

question

A nurse is teaching a parent about the behaviors that are first evident in an infant at 8 months of age. What should the nurse include? Select all that apply.

answer

-being shy with strangers -showing interest in small objects

question

A nurse in the pediatric clinic is teaching a mother how to care for her infant who has eczema. What is most important for the nurse to teach the mother?

answer

Preventing secondary infections

question

A nurse reviews with the parents of a young infant the principles of growth and development. Place the milestones in the order of their usual achievement.

answer

1. sits momentarily without support and rolls over 2. Waves bye-bye and sits alone 3. Walks alone and builds a tower of two blocks 4. Climbs stairs and drinks from a cup 5. Draws a vertical line and walks on tiptoe

question

An infant with a myelomeningocele is admitted to the pediatric intensive care unit. While the infant is awaiting surgical correction of the defect, what is the most appropriate nursing intervention?

answer

placing the infant in the prone position

question

A newborn's immunization program is started. While discussing the immunization schedule for the first 6 months with the parents, the nurse informs them that infants usually are not immunized against which disease?

answer

measles

question

For how long should a nurse maintain isolation of a child with bacterial meningitis?

answer

for 48 hours after antibiotic therapy begins

question

While a 3-month-old infant is at the well-baby clinic for a checkup, the parents express concern that their baby still has a soft spot on the top of the head. The nurse informs the parents that their infant's anterior fontanel will close around what age?

answer

13 to 18 months of age

question

What assessment finding in a newborn is suggestive of cystic fibrosis?

answer

abdominal distention

question

A parent whose infant is born with talipes equinovarus (clubfoot) tells the nurse, "I am afraid to have more children because they might have the same problem." What is the best response by the nurse?

answer

Exploring the parent's understanding of the probable causes of this disorder

question

A nurse is selecting toys for a 5-month-old infant. Which toy should not be given to the infant?

answer

large snap beads

question

An infant with hypertrophic pyloric stenosis is admitted to the pediatric unit. What does the nurse expect to find when palpating the infant's abdomen?

answer

an olive-sized mass in the right upper quadrant

question

The nurse is reviewing the problems that may occur after frequent episodes of otitis media in infants. What complications may be precipitated by this infection? Select all that apply.

answer

-mastoiditis -hearing loss -bacterial meningitis

question

What is most important for the nurse to include in the plan of care to best meet the needs of a neglected 6-month-old infant?

answer

Provide consistent caregivers who will provide stimulation that is moderate and purposeful.

question

During a parenting class a nurse is discussing infant/toddler nutrition and ways to reduce the risk of food allergies. What food item should the nurse recommend that the parents avoid until their children are 3 years old?

answer

Peanut butter

question

An 8-month-old infant undergoes surgical correction for hypospadias. What is a priority nursing intervention during the postoperative period?

answer

Minimizing pain with adequate analgesia

question

An infant is born with exstrophy of the bladder. The parents are concerned and confused when they are told that their infant will need surgery. What nursing intervention will best help the infant's parents?

answer

Demonstrating the same manner of care for the infant as for other infants on the unit

question

During change-of-shift report, the oncoming nurse receives information about a 14-month-old infant who underwent cleft palate repair the previous day. The child is currently on a full-liquid diet from cups only. No spoons or straws are allowed in the child's mouth. In addition, the child has elbow restraints on both arms. What care should the nurse include during the course of the shift?

answer

finishing each meal with a drink of water

question

A nurse is caring for an infant with bacterial meningitis. The parents ask how their baby could have contracted the illness. What does the nurse consider as the most likely route of transmission to the central nervous system?

answer

Cranial apertures or sinuses

question

A nurse is teaching parents how to facilitate their 10-week-old infant's optimal growth and development. What type of age-appropriate activity should the nurse encourage?

answer

placing the baby in an infant seat

question

A 4-month-old infant is to receive the second diphtheria/tetanus/pertussis (DTaP) immunization. The nurse reviews the infant's medical history before administering the vaccine. What information in the infant's history will influence the decision whether to administer the vaccine?

answer

high fever after the first dose

question

The nurse is admitting an 8-month-old infant with suspected bacterial meningitis to the hospital. List in order of priority the nursing actions that should be taken.

answer

1. institute respiratory isolation 2. insert an intravenous access device 3. assist with a lumbar puncutre 4. administer the prescribed antibiotics 5. monitor for signs of increased intracranial pressure (ICP)

question

A nurse is reviewing the clinical records of infants and children with cardiac disorders in whom heart failure developed. What does the nurse identify as the last sign of heart failure?

answer

peripheral edema

question

The nurse knows that additional discharge instructions are needed for parents whose infant has just undergone corrective surgery for cleft palate when the parent makes what statement?

answer

"lying on the abdomen is prohobited, so we'll keep him in an infant seat

question

The mother of a 7-month-old infant who is to be catheterized to obtain a sterile urine specimen expresses fear that this procedure may emotionally traumatize her baby. How should the nurse respond?

answer

"the procedure will not be emotionally traumatic at this age."

question

If a 5½-month-old infant's immunizations are on schedule, which immunizations does the nurse expect the infant to have had already?

answer

Two doses of diphtheria, tetanus, and pertussis vaccine

question

What physiologic alteration does the nurse expect when assessing a 6-month-old infant with bronchiolitis (respiratory syncytial virus [RSV])?

answer

prolonged expiratory phase

question

During an infant's routine visit to the pediatric clinic the nurse identifies white patches adhering to the mucosa of the infant's mouth. What is the initial action by the nurse?

answer

Swabbing a patch to obtain a specimen for a culture

question

A nurse is caring for an infant with a myelomeningocele. What does the nurse expect this infant to have that it is different from an infant with a meningocele?

answer

affected lower extremities

question

What major cause of iron-deficiency anemia should the nurse include when planning a discussion with an infant's parents?

answer

overfeeding of milk

question

A 3-week-old infant who has been vomiting for 3 days is admitted to the pediatric unit with a diagnosis of hypertrophic pyloric stenosis. What essential information should the nurse identify during the admission procedure?

answer

Respiratory status, amount and appearance of last voiding

question

An infant who underwent revision of a ventriculoperitoneal shunt is found to have meningitis, the result of an infected shunt. What clinical manifestations support this conclusion? Select all that apply

answer

-fever -lethargy -stiff neck -poor feeding

question

An infant vomits after feedings and starts to lose weight. Galactosemia is diagnosed. The nurse explains to the parents that galactosemia is an inherited autosomal recessive disorder that results in what complication?

answer

error in carbohydrate metabolism

question

most significant finding about the cause of the infant's HPS?

answer

a cousin underwent surgery for HPS

question

Which observation during a developmental appraisal of a 6-month-old infant is most important to the nurse in light of a diagnosis of hydrocephalus?

answer

head lag

question

A newborn with an anorectal anomaly undergoes anoplasty. At the 2-week follow-up visit, a series of anal dilations is started. What should the nurse recommend to the parents to help prevent the infant from becoming constipated?

answer

breastfeed if possible

question

The parent of a 5-month-old infant asks the nurse in the well-baby clinic the order in which new foods should be introduced. What does the nurse say are the best foods for an infant of this age, after cereal has been introduced?

answer

strained vegetables

question

A nurse is caring for a 3-month-old infant whose abdomen is distended and whose vomitus is bile stained. The nurse suspects an intestinal obstruction. What clinical manifestations support this suspicion? Select all that apply.

answer

-paroxysmal pain -grunting respirations

question

A 4-month-old infant is admitted directly to the pediatric unit from the primary healthcare provider's office with a diagnosis of bronchiolitis. The mother reports that the infant had a "breathing treatment" about 3 hours ago while in the primary healthcare provider's office. She says she then went home to pack some clothes first before coming to the hospital. The mother says that it has been more than 4 hours since the baby ate and requests formula and rice cereal so she can feed the baby. The admitting nurse reviews the infant's assessment findings and admission prescriptions. How should the nurse recommend that the mother feed the baby?

answer

withhold feedings at this time

question

A nurse is conducting an assessment of a young infant who is dehydrated. Which clinical sign is the most important indication of the degree of dehydration?

answer

weight loss

question

After closure of a newborn's myelomeningocele, what essential nursing intervention must be included in the plan of care?

answer

Measuring head circumference daily

question

The nurse should assess an infant with gastroesophageal reflux for what complication?

answer

respiratory problems

question

What should the nurse include in the teaching plan for parents of an infant with phenylketonuria (PKU)?

answer

Cognitive impairment occurs if PKU is untreated.

question

The nurse notes that a 6-month-old infant is startled by a loud noise but does not turn in the direction of the sound. How should the nurse interpret this response?

answer

evidence of hearing loss

question

What behavior does the nurse anticipate while feeding a newborn with choanal atresia?

answer

chokes on the feeding

question

A nurse is caring for an infant who is to undergo surgery for hypertrophic pyloric stenosis (HPS). The nurse explains to the parents that this type of surgery has a high success rate when the infant's physical status meets certain criteria. What specific criterion should be discussed with the parents?

answer

fluid and electrolyte imbalances are corrected

question

A nurse in the child health clinic is assessing a 9-month-old infant. What developmental findings does the nurse expect? Select all that apply.

answer

-enjoys push-pull toys - sits steadily without support - responds to simple commands

question

A 3-week-old infant has surgery for esophageal atresia. What is the immediate postoperative nursing care priority for this infant?

answer

checking the patency of the nasogastric tube

question

The mother of an infant with a congenital heart defect who was admitted to the pediatric unit with heart failure asks why her baby must be weighed each morning. The nurse explains that the baby's treatment is based on changes in the daily weight. What complication can be prevented if treatment is successful?

answer

fluid retention

question

A nurse is caring for a 3-month-old infant with congenital hypothyroidism. What should the parents be taught about the probable long-term effect of the condition if treatment is not begun immediately?

answer

cognitive impairment

question

The mother of an infant with hypertrophic pyloric stenosis (HPS) asks the nurse many questions about the problem. What information should the nurse convey when answering these questions?

answer

surgery is usually necessary

question

An infant undergoes corrective surgery for hypertrophic pyloric stenosis. What should the nurse teach a parent to do immediately after a feeding to limit vomiting?

answer

place the infant in an infant seat

question

A 5-month-old infant who weighs 12 lb 4 oz (5.6 kg) is receiving 8 oz (240 mL) of full-strength formula every 4 hours between 8:00 AM and midnight. In light of the recommended caloric intake of 108 kcal/kg/day, what does the nurse conclude about the amount of formula ingested?

answer

exceeds recommended requirements

question

A 1-year-old infant is brought to the well-baby clinic. Which toys should the nurse select from the play area for this infant's growth and developmental level? Select all that apply.

answer

-push-pull toy -nested boxes -squeaking plastic toy

question

The nurse anticipates that a child born with a missing chromosome is most likely to have which condition?

answer

turner syndrome

question

A 2-month-old infant is admitted to the pediatric unit for observation after an automobile collision. Family members are unable to stay. How can the nurse best provide psychologic comfort for the infant?

answer

following a routine to which the infant is accustomed

question

A 6-week-old infant is brought to the clinic by the parents. The mother states that the baby has been vomiting with increasing frequency and force after feeding. Hypertrophic pyloric stenosis (HPS) is diagnosed by the practitioner. What clinical findings of HPS does the nurse expect to identify? Select all that apply.

answer

-white vomitus -peristaltic waves -insatiable hunger

question

An infant with a myelomeningocele is scheduled for surgery to close the defect. Which nursing action best facilitates the parent-child relationship in the preoperative period?

answer

encouraging the parents to stroke their infant

question

A pale, lethargic 1-year-old infant weighs 28 lb (12.7 kg) and has a hemoglobin level of 9 g/dL (90 mmol/L). The parent tells the nurse that the infant refuses solid food when it is offered by spoon and drinks between four and six full bottles of milk per day. What should the nurse recommend?

answer

giving the infant finger foods

question

A 4-month-old infant is admitted to the pediatric unit. How does the primary nurse expect the infant to behave when approached?

answer

reach out to the nurse for the attention that is being offered

question

A nurse teaches the parents of an infant with a cardiac defect how to detect impending heart failure. What should the parents be taught to identify as an early sign?

answer

increased heart rate

question

A nurse is caring for a child with a diagnosis of meningitis. What clinical findings indicate an increase in intracranial pressure? Select all that apply.

answer

-irritabilty -bradycardia

question

A nurse is obtaining the health history of a 7-month-old who has had repeated episodes of otitis media. What question is most important for the nurse to include in the interview with the mother?

answer

"please describe your child's feeding patterns.

question

A 1-year-old infant has been admitted with a tentative diagnosis of bacterial meningitis. A lumbar puncture is performed to confirm the diagnosis. What laboratory report on the cerebrospinal fluid (CSF) supports this diagnosis?

answer

increased protein level

question

The parents of an infant tell a nurse in the pediatric clinic that they give their infant some whiskey when the baby is colicky. How should the nurse respond?

answer

"Have other parents in your family given whiskey to their babies?"

question

A nurse is reviewing the immunization schedule of a 5-month-old infant. What immunizations does the nurse expect the infant to have already received?

answer

Rotavirus, DTaP, Haemophilus influenzae, polio, pneumococcal

question

A nurse is caring for a 6-day-old preterm infant in the neonatal intensive care unit. What complications should the nurse be alert for in this infant?

answer

necrotizing enterocolitis

question

An infant who weighed 7.5 lb (3.4 kg) at birth now weighs 15 lb (6.8 kg) at 1 year. What does the nurse concludes about this infant's weight gain?

answer

signifies an inadequate weight gain

question

A nurse is assessing a 1-year-old infant. What behavior does the nurse expect to observe? Select all that apply.

answer

-tries to ascend stairs -explores away from the parent

question

A newborn is admitted to the neonatal intensive care unit (NICU) with choanal atresia. Which part of the infant's body should the nurse assess?

answer

nasopharynx

question

While working in a neuromuscular clinic the nurse monitors infants for symptoms of cerebral palsy. Which statements by infants' mothers indicate the need for further evaluation for cerebral palsy? Select all that apply.

answer

-"my baby was able to turn from front to back by 2 months of age -"all of my other children were sitting alone by this age. This baby doesn't seem to be anywhere near sitting alone"

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