Question 1

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?

Accepted Answer

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

Question 2

An infant is found to have communicating hydrocephalus. The parents ask for clarification of the health care provider\'s explanation of the problem. How should the nurse respond?

Accepted Answer

\"There is a part of the brain surface that usually absorbs spinal fluid after its production that is not functioning adequately.\"

Question 3

A nurse is teaching a class about behavioral expectations of infants and children to a group of parents. The nurse includes those behaviors expected of 8-month-old infants. (Select all that apply.)

Accepted Answer

Stranger anxiety Playing peek-a-boo Standing by holding on to furniture

Question 4

An infant with Tetralogy of Fallot becomes cyanotic and dyspneic after a crying episode. In what position should the nurse place the infant to relieve the cyanosis and dyspnea?

Accepted Answer

Knee-chest

Question 5

A child with ?-thalassemia is receiving therapy that includes multiple blood transfusions. This child is at increased risk for which complication?

Accepted Answer

-pulmonary edema

Question 6

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?

Accepted Answer

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

Question 7

After a discussion with the health care provider, the parents of an infant with patent ductus arteriosus (PDA) ask the nurse to explain once again what PDA is. How should the nurse respond?

Accepted Answer

It is a connection between the pulmonary artery and the aorta.

Question 8

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.)

Accepted Answer

Playing peek-a-boo Turning completely over Reaching to be picked up Sitting for a short time without support

Question 9

Which statement by the parents of an infant with Erb palsy indicates to the nurse that they have an accurate understanding of their infant\'s prognosis?

Accepted Answer

\"Complete recovery takes a few months.\"

Question 10

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

Accepted Answer

-affected lower extremities

Question 11

A 5-month-old infant is brought to the pediatric clinic because of exposure to an adolescent sibling with measles. The infant\'s mother asks the nurse whether her baby can be vaccinated against measles at this age. What should the nurse consider before replying?

Accepted Answer

Maternal diseases and immunizations

Question 12

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?

Accepted Answer

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

Question 13

What characteristics does a nurse expect infants and young children with failure to thrive to exhibit? (Select all that apply.)

Accepted Answer

-language deficit -tendency to illness

Question 14

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.

Accepted Answer

Instilling saline nose drops Maintaining contact precautions Suctioning mucus with a bulb syringe

Question 15

While performing care of an infant with hypertrophic pyloric stenosis (HPS) the nurse observes visible peristaltic waves. What other sign of HPS should the nurse expect?

Accepted Answer

Small mass in the right upper quadrant

Question 16

A 3-month-old infant has been hospitalized with respiratory syncytial virus (RSV). What is the priority intervention?

Accepted Answer

Clustering care to conserve energy

Question 17

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.

Accepted Answer

Fever Stiff neck Poor feeding

Question 18

The nurse is teaching a parent group about the reason to adhere to the immunization schedule. What complication of mumps is important for adolescents to avoid?

Accepted Answer

Sterility

Question 19

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

Accepted Answer

Textured book Stuffed animal Hanging mobile

Question 20

Phenobarbital is prescribed for an infant who has had repeated seizures. One week later, at the follow-up visit, the infant is lethargic and the mother states that the infant is sleeping excessively. The infant\'s mother asks the nurse what is happening to her baby. What should the nurse tell the mother?

Accepted Answer

\"This is a response to the medication that will subside eventually.\"

Question 21

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?

Accepted Answer

Rubeola

Question 22

A complete blood count is ordered for a 5-month-old infant with Tetralogy of Fallot. What does the nurse expect to see when reviewing the laboratory results?

Accepted Answer

Polycythemia

Question 23

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.)

Accepted Answer

White vomitus  Peristaltic waves   Insatiable hunger

Question 24

A 4-month-old infant is brought to the emergency department after 2 days of diarrhea. The infant is listless and has sunken eyeballs, a depressed anterior fontanel, and poor tissue turgor. The infant\'s breathing is deep, rapid, and unlabored. The mother states that the infant has had liquid stools and no obvious urine output. What problem does the nurse conclude that the infant is experiencing?

Accepted Answer

-metabolic acidosis

Question 25

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.)

Accepted Answer

-metallic mirror -colorful mobile

Question 26

n intravenous line is inserted in the scalp vein of an infant. The mother asks why the IV is not placed in the hand or arm as for an adult. How should the nurse respond?

Accepted Answer

\"Usually veins in the arm or hand are used, but your baby\'s were too small.\"

Question 27

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

Accepted Answer

Cognitive impairment

Question 28

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

Accepted Answer

For 48 hours after antibiotic therapy begins

Question 29

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?  Correct1 Encouraging the parents to stroke their infant

Accepted Answer

Encouraging the parents to stroke their infant

Question 30

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.

Accepted Answer

1.Sits momentarily without support and rolls over 2.aves 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 31

The mother of an infant with hypertrophic pyloric stenosis states that she has never heard of this disorder and asks many questions. What should the nurse emphasize when responding?

Accepted Answer

\"This disorder has an excellent prognosis.\"

Question 32

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?

Accepted Answer

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

Question 33

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.)

Accepted Answer

Being shy with strangers Showing interest in small objects

Question 34

A 4-month-old infant had a spica cast applied. What should the nurse include in the discharge instructions to the parents?

Accepted Answer

Obtain a specially designed car seat.

Question 35

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.)

Accepted Answer

Fetal iron reserves are depleted Food can be taken from a spoon.

Question 36

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

Accepted Answer

There is an obstruction above the opening of the common bile duct.

Question 37

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

Accepted Answer

Following a routine to which the infant is accustomed

Question 38

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?

Accepted Answer

Providing formula thickened with cereal

Question 39

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?

Accepted Answer

Straining at stool

Question 40

A nurse is caring for an infant with hydrocephalus after the insertion of a shunt. How should the nurse evaluate the effectiveness of the shunt?

Accepted Answer

By palpating the anterior fontanel

Question 41

A 3-month-old infant with chronic constipation has a tentative diagnosis of Hirschsprung disease. What definitive diagnostic test does the nurse expect to prepare the infant for?

Accepted Answer

rectal biopsy

Question 42

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?

Accepted Answer

Finishing each meal with a drink of water

Question 43

A 2-month-old infant is to have a nasogastric tube inserted. The nurse expects that:

Accepted Answer

A pacifier will be offered to lessen gagging and allow easier insertion of the tube

Question 44

A nurse is discussing the diet of an 8-month-old infant with the parents. Which foods can an infant of this age on a regular diet safely be fed? (Select all that apply.)

Accepted Answer

Pureed pears Pureed carrots Mashed sweet potatoes

Question 45

The parents of an infant who just underwent insertion of a ventriculoperitoneal shunt for hydrocephalus are concerned about the prognosis. What information should the nurse give the parents?

Accepted Answer

The shunt may need to be replaced as the child grows older.

Question 46

What is the nurse\'s priority concern when caring for an infant born with exstrophy of the bladder?

Accepted Answer

Development of an infection

Question 47

A newborn with an anorectal anomaly undergoes anoplasty performed. 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?

Accepted Answer

Breastfeed if possible.

Question 48

A nurse is concerned about helping the parents of an infant with cerebral palsy set long-term goals for the family. These goals should be set with the understanding that:

Accepted Answer

Unknown extent of the disability requires continual adjustments

Question 49

A nurse is caring for an infant with talipes equinovarus (clubfoot) who has had a corrective boot cast applied. Which peripheral vascular observation cannot be performed while the cast is in place?

Accepted Answer

pulse

Question 50

A mother arrives in the emergency department with her severely dehydrated infant. After being treated aggressively, the infant is rehydrated and ready to be discharged. What is the priority concern that should be included in the discharge teaching plan for the mother?

Accepted Answer

Signs of dehydration in infants

Question 51

A nurse provides clapping, percussion, and postural drainage every 4 hours for a 3-month-old infant with cystic fibrosis. When is the best time for the nurse to schedule chest physiotherapy?

Accepted Answer

2 hours after feedings

Question 52

An infant is found to have hydrocephalus. Which finding alerts the nurse to suspect increasing intracranial pressure?

Accepted Answer

Projectile vomiting

Question 53

An infant is found to have developmental dysplasia of the hip (DDH) 6 weeks after birth. The parents ask a nurse at the clinic why their infant must be restrained in a harness at such an early age. How should the nurse respond?

Accepted Answer

Infants\' hip joints are cartilaginous, allowing molding of the acetabulum.

Question 54

A 5-month-old infant is admitted with a diagnosis of respiratory syncytial virus (RSV) infection. The infant\'s condition suddenly deteriorates and a dose of epinephrine is prescribed to relieve bronchospasm. For what side effect of the medication should the nurse evaluate the infant?

Accepted Answer

Tachycardia

Question 55

What is the priority nursing action when a 3-month-old infant is receiving intravenous (IV) fluids by way of an antecubital vein?

Accepted Answer

Applying arm boards to prevent bending at the elbows

Question 56

The parents of an infant who is to undergo insertion of a right ventriculoperitoneal shunt for hydrocephalus are taught about postoperative positioning that helps prevent pressure on the valve site. What statement indicates that they understand the teaching?

Accepted Answer

\"The flat left side-lying position is the safest position for our baby.\"

Question 57

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

Accepted Answer

Picking up a toy and putting it in the mouth

Question 58

The nurse observes the interaction between the mother and her 9-month-old infant. Which observation requires further evaluation?

Accepted Answer

The mother speaks in baby talk.

Question 59

A family has decided to withhold extraordinary care for a newborn with severe abnormalities. How should the nurse interpret this decision?

Accepted Answer

The newborn is being allowed to die.

Question 60

A cast is applied to the involved extremity of an infant with talipes equinovarus (clubfoot). The nurse tells the parents that they will have to bring their baby back to the clinic for a cast change:

Accepted Answer

each week

Question 61

A severely dehydrated infant admitted to the pediatric unit is too lethargic to receive oral rehydration therapy, and an intravenous infusion is started. What is the nurse\'s primary responsibility?

Accepted Answer

Monitoring the prescribed rate of flow

Question 62

A nurse is caring for an infant who has undergone myringotomy because of recurrent otitis media. What does the nurse expect to note when providing care to this child?

Accepted Answer

Drainage into the external auditory canal

Question 63

An infant who is exhibiting signs of increased intracranial pressure (ICP) is admitted to the pediatric intensive care unit. What care should the nurse implement that is specific for this infant\'s condition?

Accepted Answer

Elevating the infant\'s head higher than the hips

Question 64

A nurse is caring for a 3-month-old infant who was admitted to the pediatric unit with severe dehydration caused by diarrhea. After fluid and electrolyte balance is restored, Lactobacillus granules (Lactinex) are prescribed. The nurse expects this medication to:

Accepted Answer

Recolonize flora in the intestinal tract

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