NURSING 4710 Infant Exam Questions & Answers

NURSING 4710 Infant Exam Questions & Answers Question 1 See full question Parents bring their infant to the clinic, seeking treatment for vomiting and diarrhea that has lasted for 2 days. On assessment, the nurse detects dry mucous membranes and lethargy. What other finding suggests a fluid volume deficit? You Selected: • A sunken fontanel Correct response: • A sunken fontanel Explanation: In an infant, signs of fluid volume deficit (dehydration) include sunken fontanels, increased pulse rate, and decreased blood pressure. They occur when the body can no longer maintain sufficient intravascular fluid volume. When this happens, the kidneys conserve water to minimize fluid loss, which results in concentrated urine with a high specific gravity. Question 2 See full question A mother of a hospitalized infant appears anxious and displays anger with the staff. Which response is most appropriate? You Selected: • "You seem upset. Having your child hospitalized must be difficult." Correct response: • "You seem upset. Having your child hospitalized must be difficult." Explanation: Acknowledging the mother's feelings and recognizing that it's difficult to cope with a hospitalized child allows the mother to express her feelings. Telling the mother that other staff members don't want to talk to her isn't therapeutic. Asking her to explain her behavior places the mother on the defensive and also isn't therapeutic. Question 3 See full question An infant who has been in foster care since birth requires a blood transfusion. Who is authorized to give written, informed consent for the procedure? You Selected: • The foster mother Correct response: • The foster mother Explanation: When children are minors and aren't emancipated, their parents or designated legal guardians are responsible for providing consent for medical procedures. Therefore, the foster mother is authorized to give consent for the blood transfusion. The social worker, the nurse, and the nurse manager have no legal rights to give consent in this scenario. Question 4 See full question The most appropriate toys to give to a 5-month-old infant are: You Selected: • soft, washable toys. Correct response: • soft, washable toys. Explanation: Soft, washable toys are appropriate for infants, who tend to place everything in their mouths. These toys are not harmful. Plastic toys cannot be manipulated by a child of this age, and the child would put the car in the mouth, which may not be safe due to small parts that may be swallowed or aspirated. Games and puzzles are too advanced for a 5-month-old, and the child could put the pieces in the mouth and swallow them. Some stuffed animals have eyes that can be swallowed or aspirated. Question 5 See full question Which serum electrolytes findings should the nurse expect to find in an infant with persistent vomiting? You Selected: • K+, 3.2; Cl-, 92; Na+, 120 Correct response: • K+, 3.2; Cl-, 92; Na+, 120 Explanation: Chloride and sodium function together to maintain fluid and electrolyte balance. With vomiting, sodium chloride and water are lost in gastric fluid. As dehydration occurs, potassium moves into the extracellular fluid. For these reasons, persistent vomiting can lead to hypokalemia, hypochloremia, and hyponatremia. The normal potassium level is 3.5 to 5.5, the normal chloride level is 98 to 106, and the normal sodium level is 135 to 145. The values of 3.2, 92, and 120, respectively, are consistent with persistent vomiting. Each of the other options includes at least two serum electrolyte levels that are normal or high. These are not consistent with persistent vomiting. Question 1 See full question The physician suspects tracheoesophageal fistula in a 1-day-old neonate. Which nursing intervention is most appropriate for this child? You Selected: • Elevating the neonate's head and giving nothing by mouth Correct response: • Elevating the neonate's head and giving nothing by mouth Explanation: Because of the risk of aspiration, a neonate with a known or suspected tracheoesophageal fistula should be kept with the head elevated at all times and should receive nothing by mouth (NPO). The nurse should suction the neonate regularly to maintain a patent airway and prevent pooling of secretions. Elevating the neonate's head after feedings or giving glucose water are inappropriate because the neonate must remain on NPO status. Question 2 See full question An infant is hospitalized for treatment of inorganic failure to thrive. Which nursing action is most appropriate for this child? You Selected: • Maintaining a consistent, structured environment Correct response: • Maintaining a consistent, structured environment Explanation: The nurse caring for an infant with inorganic failure to thrive should strive to maintain a consistent, structured environment because it reinforces a caring feeding environment. Encouraging the infant to hold a bottle would reinforce an uncaring feeding environment. The infant should receive social stimulation rather than be confined to bed rest. The number of caregivers should be minimized to promote consistency of care. Question 3 See full question When teaching a group of parents about the potential for febrile seizures in children, which fact should the nurse include? You Selected: • The seizures occur as the fever rises. Correct response: • The seizures occur as the fever rises. Explanation: Febrile seizures commonly occur as the fever rises. The exact cause of febrile convulsions is not known. Infants and young toddlers are the age-groups primarily affected. Febrile seizures typically do not follow immunization administration. Question 4 See full question An infant is being treated at home for bronchiolitis. What should the nurse teach the parent about home care? Select all that apply. You Selected: • watching for difficulty breathing • offering small amounts of fluids frequently Correct response: • offering small amounts of fluids frequently • watching for difficulty breathing Explanation: An infant with bronchiolitis will have increased respirations and will tire more quickly, so it is best and easiest for the infant to take fluids more often in smaller amounts. The parents also would be instructed to watch for signs of increased difficulty breathing, which signal possible complications. Healthy infants and even those with bronchiolitis should sleep in the supine position. Calling the clinic for an episode of vomiting would not be necessary. However, the parents would be instructed to call if the infant cannot keep down any fluids for a period of more than 4 hours. Parents would not need to record how much the infant drinks. Chest physiotherapy is not indicated because it does not help and further irritates the infant. Question 5 See full question 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. Your Response: • 200 Correct response: • 200 Explanation: The nurse would calculate the correct dose by multiplying the infant’s weight by the ordered rate: 8 kg x 25 mg/kg = 200 mg. Question 1 See full question After an infant undergoes surgical repair of a cleft lip, the physician orders elbow restraints. For this infant, the postoperative care plan should include which nursing action? You Selected: • Removing the restraints every 2 hours Correct response: • Removing the restraints every 2 hours Explanation: Question 2 See full question An infant who weighs 7.5 kg is to receive ampicillin 25 mg/kg intrvenously every 6 hours. How many milligrams would the nurse administer per dose? Record your answer using one decimal place. Your Response: • 187.5 Correct response: • 187.5 Explanation: Question 3 See full question A normal, healthy infant is brought to the clinic for the first diptheria, tetanus, acellular pertussis (Dtap) immunization. Which route is appropriate to administer this vaccine? You Selected: • IM Correct response: • IM Explanation: Question 4 See full question An 8-month-old infant is brought to the emergency department (ED) following a fall from his high chair. The child is awake, alert, and crying. Which intervention should the nurse prepare? You Selected: • Monitoring the child for 24 hours in the ED, then discharge to home if no complications are noted Correct response: • Discharge to home with instructions to the parents for head injury Explanation: The child is showing no signs of deficit from head injury at this time and should therefore be discharged with instructions to the parents on what to look for in the subsequent hours following the fall. Given that the child is awake and alert, there are no signs that further observation or admission is required, nor is there any indication for surgery at this time. Question 5 See full question The nurse is caring for an infant who exhibits the above characteristics. When planning care, which would be the best long term client goal? You Selected: • The client will care for himself/herself without supervision. Correct response: • The client will reach his/her optimal level of functioning. Explanation: Down syndrome results from trisomy of chromosome 21 and is evidenced by various physical and cognitive impairments. Common physical characteristics include a flat, broad nasal bridge, inner epicanthal folds, slanted eyes, a protruding tongue, a short neck, hypotonia and a palmar crease. Nursing interventions include supporting the parents through the diagnostic process, monitoring for cardiac or respiratory problems with a long term goal to help to assist the client to reach his optimal level of functioning. Specific goals include feeding, personal care and communication skills. Question 1 See full question The nurse is assessing the development of a 7-month-old. The child should be able to: You Selected: • sit without support. Correct response: • sit without support. Explanation: The majority of infants (90%) can sit without support by 7 months of age. Approximately 75% of infants at 10 months of age are able to play pat-a-cake. The ability to say two words occurs in 90% of children by age 16 months. A child typically can wave bye-bye at about 14 months of age. Question 2 See full question After teaching the parent of an infant who has had a surgical repair for a cleft lip about the use of elbow restraints at home, the nurse determines that the teaching has been successful when the parent makes which statement? You Selected: • "We will keep the restraints on during the day while he is awake, but take them off when we put him to bed at night." Correct response: • "We will keep the restraints on continuously except when checking the skin under them for redness." Explanation: To keep the infant from disturbing the suture line by placing fingers or other objects in the mouth, either intentionally or accidentally, the restraints should be in place at all times. They should be removed for a short period, however, so that the underlying skin can be checked for any redness or breakdown. While the restraints are removed, the parents should be instructed to manually restrain the hands and arms. Question 3 See full question A parent tells the nurse that their 8-month-old infant is anxious. Which suggestion by the nurse is most appropriate to help the parent lessen anxiety in the infant? You Selected: • Talk quietly to the infant while he is awake. Correct response: • Talk quietly to the infant while he is awake. Explanation: Infants are sensitive to stress in their caretakers. The best way to handle an anxious infant is to talk quietly, thereby soothing the infant. Limiting holding of the infant to feeding periods interferes with meeting the infant’s needs for close contact, possibly compromising his ability to develop trust. Playing music in the room for most of the day and night will make it difficult for the infant to differentiate days from nights. Having a friend take the infant for several days will not necessarily take care of the problem because when the infant returns to the parents, the same behaviors will recur unless the parents makes some changes. Question 4 See full question A parent brings their 7-month-old child to the emergency department stating the child is not responsive. The unlicensed assistive personnel (UAP) checks the pulse as requested and the nurse observes them obtaining the pulse in the inappropriate location. What should the nurse inform the UAP at this time? You Selected: • "To assess a pulse under age 1, you should check the brachial artery." Correct response: • "To assess a pulse under age 1, you should check the brachial artery." Explanation: The brachial artery is the best location for evaluating the pulse of an infant younger than age 1. A child of this age has a very short and often fat neck, so that carotid artery is inaccessible. The femoral artery is usually inaccessible because of clothing and diapers. The radial artery may not be palpable if cardiac output is low, even if there is a heart beat. The other statements are not examples of educating the UAP. Question 5 See full question The nurse is caring for the following infant after surgery. Which short term goal is the priority? You Selected: • The infant will remain infection free in the postoperative period. Correct response: • The infant will remain infection free in the postoperative period. Explanation: The client has spinal bifida with a myelomeningocele (protrusion of the spinal cord and meninges). Surgery is completed within the first days of life. Following surgery and in the recovery period, it is most important to maintain meticulous care to the incision to reduce the potential for infection. Infection can spread through the incision and up the spinal tract to the brain. All other goals are important but not as great a priority as infection. Question 1 See full question The parent of a 2-week-old infant brings the child to the clinic for a checkup. The parent expresses concern about the baby’s breathing because the infant breathes quickly for a while and then breathes slowly. The nurse interprets this finding as an indication of what factor? You Selected: • a normal pattern in infants of this age Correct response: • a normal pattern in infants of this age Explanation: The infant is exhibiting periodic breathing, which is normal in infants of this age. The infant typically alternates short periods of rapid, louder respirations with periods of slower, quieter respirations. Question 2 See full question Three weeks after an infant receives a spica cast, the mother calls the nurse because the infant’s toes are swollen and cool to the touch. What should the nurse instruct the mother to do? You Selected: • Have the child fitted for a larger cast. Correct response: • Have the child fitted for a larger cast. Explanation: Infants grow rapidly and may require application of a larger cast. A cast adequate for an infant after surgery may be outgrown in less than 1 month. The cast becomes too tight, impairing circulation evidenced by toe swelling and coolness to touch. The mother should keep the child’s feet in a recumbent position. When feet are dependent in a cast, decreased venous return may occur. Reduced venous return along with decreased feet and leg movement subsequently leads to edema, which resolves when the feet are returned to a recumbent position. The cotton wadding used to line the cast does not shrink over time. If the child had surgery, the chances of infection are minimal after a 3- to 4-week period. In addition, other symptoms of infection, such as fever and possibly a hot spot on the cast, would be present. Question 3 See full question Which parental characteristic is least likely to be a risk factor for child abuse? You Selected: • being a member of a large family Correct response: • being a member of a large family Explanation: From documented cases of child abuse, a profile has emerged of a high-risk parent as a person who is isolated, impulsive, impatient, and single with low self-esteem, a history of substance abuse, a lack of knowledge about a child’s normal growth and development, and multiple life stressors. Just because a parent comes from a large family, there is no increase in the incidence of the parent abusing their own children unless they possess the other risk factors. Question 4 See full question When teaching the parents of an infant how to perform back slaps to dislodge a foreign body, what should the nurse tell the parents to use to deliver the blows? You Selected: • heel of the hand Correct response: • heel of the hand Explanation: Back slaps are delivered rapidly and forcefully with the heel of the hand between the infant’s shoulder blades. Slowly delivered back slaps are less likely to dislodge the object. Using the heel of the hand allows more force to be applied than when using the palm or the whole hand, increasing the likelihood of loosening the object. The fingertips would be used to deliver chest compressions to an infant younger than 1 year of age. Question 5 See full question A 6-month-old child is taken to the pediatrician, and the mother states that the child is not growing like other children of similar age in families she knows. The birth weight of the child was 7 pounds 11 ounces, (3,495 g) and the current weight is 11 pounds 2 ounces (5,057 g). Based on these findings, the nurse tells the mother: You Selected: • "Your infant's weight is below the normal range based on the infant's age. Let's start with a few questions regarding your infant's eating habits". Correct response: • "Your infant's weight is below the normal range based on the infant's age. Let's start with a few questions regarding your infant's eating habits". Explanation: Birth weight usually doubles by age 6 months and triples by age 1 year. Therefore, this infant should weigh 14 lb (6.4 kg). Watchful waiting or no action is detrimental to the infant’s growth and development. Comparison to other children is not helpful. Asking about the child's eating habits will help the nurse get a better understanding of potential causes of the low birth weight. The parents should be advised that the birth weight is below normal. Question 1 See full question When teaching the parent of an infant with Hirschsprung's disease who received a temporary colostomy about the types of foods the infant will be able to eat, which diet would the nurse recommend? You Selected: • high-fiber diet Correct response: • regular diet Explanation: A regular diet would be recommended for the child with a colostomy; no special diet is needed. A high-fiber diet is not necessary. Fat is necessary for brain growth in the first year of life. A high-residue diet would result in bulkier stools and increased gas production, which will collect in the colostomy bag. Therefore, a high-residue diet is not indicated. Question 2 See full question A 1-year-old child is admitted to the hospital with sickle cell crisis. Which intervention will be a part of the child’s plan of care? You Selected: • parenteral iron therapy Correct response: • IV fluid therapy Explanation: During a sickle cell crisis, increasing the transport and availability of oxygen to the body’s tissues is paramount. Administering a high volume of IV fluid and electrolytes to help compensate for the acidosis resulting from hypoxemia associated with sickle cell crisis is one way to accomplish this. Fluid administration also helps overcome dehydration, a possible predisposing factor common in children with sickle cell crisis. Iron therapy is contraindicated for this condition. Exchange transfusions are used only in certain situations, such as severe hyperbilirubinemia. Small amounts of blood are removed from the infant and replaced with whole blood. This helps to correct the anemia and lower bilirubin levels. Although anticoagulants have been suggested, they are not included in the usual treatment of sickle cell crisis. Question 3 See full question A 5-month-old infant is brought to the clinic by his parents because he “cries too much” and “vomits a lot.” The infant’s birth weight was 6 lb, 10 oz (3,000 g), and his current weight is 7 lb, 4 oz (3,289 g), falling below the 5th percentile on a standard growth chart. Which data should the nurse identify as the priority? You Selected: • pattern of weight gain Correct response: • feeding pattern Explanation: Because the infant falls below the 5th percentile on a standard growth chart, the nurse should consider failure to thrive, a term applied to an infant who is not growing at an acceptable rate. Information about feeding patterns, including types and amounts of food, is needed to determine the cause of failure to thrive. If a child does not receive sufficient calories, growth slows. Whether or not the infant has received regular checkups is important but not the priority because that information alone does not provide evidence or substantiation about the infant’s growth patterns. The infant’s pattern of weight gain is important but not the priority. Rather, the infant’s pattern of weight gain provides valuable and useful information over a period of time. Information about family dynamics is important to provide data about family stresses that may affect or help explain the infant’s failure to thrive. However, it is not the priority. This information needs to be viewed in conjunction with the infant’s feeding patterns to gain a complete picture. Question 4 See full question A mother and grandmother bring a 2-month-old infant to the clinic for a routine checkup. As the nurse weighs the infant, the grandmother asks, "Shouldn't the baby start eating solid food? My kids started on cereal when they were 2 weeks old." Which response by the nurse would be appropriate? You Selected: • "Babies can't digest solid food properly until they're 3 or 4 months old." Correct response: • "Babies can't digest solid food properly until they're 3 or 4 months old." Explanation: Stating that babies can't digest solid food properly is correct because infants younger than 3 or 4 months lack the enzymes needed to digest complex carbohydrates. Saying that there's no need for solid food doesn't address the grandmother's question directly. Saying that things have changed is a cliché that may block further communication with the grandmother. Stating that introducing solid food early leads to eating disorders is incorrect because no evidence suggests that this occurs. Question 5 See full question Which assessment should be the priority for an infant who has had surgery to correct an intussusception and is now at risk for development of a paralytic ileus postoperatively? You Selected: • inspection of the first stool passed Correct response: • auscultation of bowel sounds Explanation: Development of a paralytic ileus postoperatively is a functional obstruction of the bowel. Bowel sounds initially may be hyperactive, but then they diminish and cease. Measurement of urine specific gravity provides information about fluid and electrolyte status. The first stool and the amount of gastric output provide information about the return of gastric function. Question 1 See full question A new mot