peds2 infant

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
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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?
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“There is a part of the brain surface that usually absorbs spinal fluid after its production that is not functioning adequately.”
question

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.)
answer

Stranger anxiety Playing peek-a-boo Standing by holding on to furniture
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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?
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Knee-chest
question

A child with β-thalassemia is receiving therapy that includes multiple blood transfusions. This child is at increased risk for which complication?
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-pulmonary edema
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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
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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?
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It is a connection between the pulmonary artery and the aorta.
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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.)
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Playing peek-a-boo Turning completely over Reaching to be picked up Sitting for a short time without support
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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?
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“Complete recovery takes a few months.”
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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?
answer

-affected lower extremities
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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?
answer

Maternal diseases and immunizations
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?
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“The tube has been placed to drain the air that entered the chest cavity during surgery.”
question

What characteristics does a nurse expect infants and young children with failure to thrive to exhibit? (Select all that apply.)
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-language deficit -tendency to illness
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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
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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?
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Small mass in the right upper quadrant
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A 3-month-old infant has been hospitalized with respiratory syncytial virus (RSV). What is the priority intervention?
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Clustering care to conserve energy
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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.
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Fever Stiff neck Poor feeding
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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?
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Sterility
question

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.)
answer

Textured book Stuffed animal Hanging mobile
question

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?
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“This is a response to the medication that will subside eventually.”
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?
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Rubeola
question

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?
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Polycythemia
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
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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?
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-metabolic acidosis
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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
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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?
answer

“Usually veins in the arm or hand are used, but your baby’s were too small.”
question

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

For 48 hours after antibiotic therapy begins
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? Correct1 Encouraging the parents to stroke their infant
answer

Encouraging the parents to stroke their infant
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.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

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?
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“This disorder has an excellent prognosis.”
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?
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The mother says the infant stopped making verbal sounds about a month ago.
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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.)
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Being shy with strangers Showing interest in small objects
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A 4-month-old infant had a spica cast applied. What should the nurse include in the discharge instructions to the parents?
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Obtain a specially designed car seat.
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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 reserves are depleted Food can be taken from a spoon.
question

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?
answer

There is an obstruction above the opening of the common bile duct.
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 psychological comfort for the infant?
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Following a routine to which the infant is accustomed
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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

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
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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?
answer

By palpating the anterior fontanel
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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?
answer

rectal biopsy
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 2-month-old infant is to have a nasogastric tube inserted. The nurse expects that:
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A pacifier will be offered to lessen gagging and allow easier insertion of the tube
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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.)
answer

Pureed pears Pureed carrots Mashed sweet potatoes
question

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?
answer

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

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

Development of an infection
question

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?
answer

Breastfeed if possible.
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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:
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Unknown extent of the disability requires continual adjustments
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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?
answer

pulse
question

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?
answer

Signs of dehydration in infants
question

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?
answer

2 hours after feedings
question

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

Projectile vomiting
question

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?
answer

Infants’ hip joints are cartilaginous, allowing molding of the acetabulum.
question

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?
answer

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

Applying arm boards to prevent bending at the elbows
question

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?
answer

“The flat left side-lying position is the safest position for our baby.”
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
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The nurse observes the interaction between the mother and her 9-month-old infant. Which observation requires further evaluation?
answer

The mother speaks in baby talk.
question

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

The newborn is being allowed to die.
question

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:
answer

each week
question

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?
answer

Monitoring the prescribed rate of flow
question

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?
answer

Drainage into the external auditory canal
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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?
answer

Elevating the infant’s head higher than the hips
question

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:
answer

Recolonize flora in the intestinal tract
question

An infant has a plaster cast applied for clubfoot correction. What nursing intervention will hasten drying of the cast?
answer

Exposing the casted extremity
question

The parent of a newborn asks a nurse why, except for hepatitis B vaccine, the immunization schedule does not start until the infant is 2 months old. How should the nurse respond?
answer

“Maternal antibodies interfere with the development of active antibodies by the infant when immunize
question

What clinical manifestation of tetralogy of Fallot should the nurse expect when caring for an infant with this diagnosis?
answer

Clubbing of fingers
question

An infant who has been found to have developmental dysplasia of the hip (DDH) is being examined in the pediatric clinic. What clinical finding does the nurse expect the health care provider to identify during the physical assessment?
answer

Limited abduction of the affected hip
question

A mother whose infant was found to have cerebral palsy at 6 months of age asks why she was not told that her baby had cerebral palsy when the infant was born. How should the nurse respond?
answer

question

A 6-month-old infant is to receive scheduled immunizations. The parents ask why two influenza vaccines are given: Haemophilus influenzae type B (Hib) and pneumococcal conjugate vaccine (PCV). How should the nurse respond?
answer

PCV and Hib are given together to protect against viral and bacterial diseases
question

An infant is born with a cleft lip. What nursing intervention is unique to infants with cleft lip?
answer

Using modified techniques for feeding
question

A nurse teaches the parents of a 1-year-old infant that the primary developmental milestone to be accomplished between 12 and 15 months of age is the ability to:
answer

Correct1 Walk erect
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 healthy12-month-old infant?
answer

29% to 41%
question

A 3-month-old infant is admitted to the pediatric unit with a diagnosis of tetralogy of Fallot. The nurse’s infant’s weight has declined from the 25th percentile to the 5th. The nurse concludes that the most likely reason for this inadequate weight gain is:
answer

Correct4 Inadequate oxygen perfusion leading to activity intolerance, resulting in diminished energy to nurse
question

The parents of a 3-month old infant who is breastfed ask the nurse how to prevent nutritional anemia. What is the best response by the nurse?
answer

Baby cereal or an iron supplement should be given around 4 months of age
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

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