Test Bank for Pediatric Nursing: A Case-Based Approach, 2nd
Edition by Tagher
Chapter 01: Chip Jones: Bronchiolitis
1. A nurse is providing care for a 4-month-old infant at the pediatric clinic. During the
assessment the nurse should expect that the infant has reached which developmental
milestone(s)? Select all that apply.
A. Uses pincer grasp to pick up items
B. Can roll over from front onto back
C. Pulls self up to a standing position
D. Recognizes family members' faces
E. Pushes self up on arms from a prone position
F. Sits with support
ANS: B, D, E, F
Rationale: At 4 months of age, an infant is able to roll over from prone to supine position,
push the head/chest up on arms from a prone position, sit with support and recognize the faces
of close family members. The use of the pincer grasp and the ability to pull self up to a
standing position are expected at 10 months of age.
PTS: 1 REF: p. 4 OBJ: 1
NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter 1: Chip Green: Bronchiolitis BLM: Cognitive Level: Understand
2. A nurse is assessing a 3-month-old infant during a pediatric clinic visit. The nurse believes the
infant is demonstrating early manifestations of respiratory distress. Which clinical
manifestation(s) should the nurse document? Select all that apply.
, A. Bradycardia
B. Acrocyanosis
C. Intercostal retractions
D. Nasal congestion
E. Tachypnea
ANS: D, E
Rationale: Early signs of respiratory distress in an infant include fussiness, nasal congestion,
tachypnea and no interest in feeding. Intercostal retractions are signs of moderate distress;
bradycardia can be seen with severe respiratory distress. Acrocyanosis, in and of itself, is not
a sign of respiratory distress as it can be caused by poor circulation and cold extremities.
PTS: 1 REF: p. 8 OBJ: 4
NAT: Client Needs: Physiological Integrity: Physiological Adaptation
TOP: Chapter 1: Chip Green: Bronchiolitis BLM: Cognitive Level: Apply
3. A nurse is caring for an infant newly admitted for suspected bronchiolitis. The infant's parent
is very upset and states "I am so worried about my infant. What can you do to help my
infant?" What is the nurse's best response?
A. "There is no need to worry; we care for cases like this all the time."
B. "I know this is hard for you but do not worry. We will be able to discharge your
infant in a few days."
C. "No worries; having you hold the infant is very helpful. The infant will be back at
home in no time."
D. "I know it is difficult to see your infant like this. We will suction your infant and
give oxygen to make the infant comfortable.
ANS: D
Rationale: The option that states that it is difficult to see the infant like this is the only
response that explains to the parent what the nurse can do to help the infant and acknowledges
the parent's concern. The remaining options recognize the parent's concern but do not answer
the parent's question.
PTS: 1 REF: p. 10 OBJ: 7
NAT: Client Needs: Psychosocial Integrity
TOP: Chapter 1: Chip Green: Bronchiolitis BLM: Cognitive Level: Apply
4. A 3-month-old infant is hospitalized with a diagnosis of bronchiolitis. The nurse is creating a
plan of care for the infant. Which intervention is a priority?
A. Provide parental teaching on the antibiotics the infant will need to take at home.
B. Administer oxygen to maintain the infant's oxygen saturation at or above 92%.
C. Allow the parents to remain by the infant's side throughout the hospitalization.
D. Keep the infant NPO until the condition has resolved.
ANS: B
Rationale: Therapeutic management of bronchiolitis includes the administration of oxygen to
maintain O2 saturation at 92% or higher. Current evidence shows that antibiotics do not
improve outcomes in the treatment of bronchiolitis. Infants with bronchiolitis are encouraged
to feed as tolerated to maintain nutrition and fluid balance. While it is important for the
parents to be allowed to remain at the infant's side, it is not the priority.
PTS: 1 REF: p. 14 OBJ: 7
NAT: Client Needs: PhysiN
olU
ogRicSalIIN
ntG
eg-
r iT
t yE
: PShT
ysBioAloNgK
ic.
al C
AOdaMptation
TOP: Chapter 1: Chip Green: Bronchiolitis BLM: Cognitive Level: Apply
5.
, A nurse is caring for an infant admitted with a diagnosis of bronchiolitis. The nurse completes
an assessment with the above findings. What is the nurse's priority in providing care to this
infant?
A. Providing adequate fluids
B. Initiating tube feedings
C. Administering oxygen
D. Administering antipyretics
ANS: C
Rationale: The priority in providing care for this infant is to administer oxygen to increase the
O2 saturation to 92% or higher. Providing the infant adequate fluids and administering
antipyretics is also important, but these actions are not the priority. There is no need to initiate
tube feedings for this client.
PTS: 1 REF: p. 11 OBJ: 8
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter 1: Chip Green: Bronchiolitis BLM: Cognitive Level: Analyze
6. An infant is diagnosed with bronchiolitis. The nurse is teaching the parent of how to use a
bulb suction to clear the infant's airway. What is the best way for the nurse to evaluate the
effectiveness of the teaching?
A. Guide the parent step by step through the procedure.
B. Have the parent verbalize each step of the procedure.
C. Observe the parent as he/she suctions the infant.
D. Provide the parent with written instructions of the procedure.
ANS: C
Rationale: The best way N foUrR
thS
eInuNrG
se-tT
oEevSaT
luB
atA
eNthKe.pC
arO
enMt's understanding of the teaching is
for the parent to give a return demonstration so the nurse can observe the parent's technique.
Having the parent verbalize the steps of the procedure will only tell the nurse that the parent
remembered what was said; this does not assess the parent's ability to perform the procedure.
Guiding the parent step by step or providing the parent with written instructions will not help
the nurse evaluate the parent's understanding.
PTS: 1 REF: p. 11 OBJ: 8
NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter 1: Chip Green: Bronchiolitis BLM: Cognitive Level: Apply
7. Which statement best describes the difference between an infant's respiratory tract and that of
an adult?
A. The infant's respiratory tract has more alveoli than the adult.
B. The trachea and bronchi have smaller lumens in the infant.
C. Because of the location of an infant's trachea airway obstruction is less likely.
D. Adults have more soft tissue surrounding the trachea than infants.
ANS: B
Rationale: The infant's respiratory tract has smaller bronchi and fewer alveoli than adults. An
infant's neck is shorter, and the trachea lumen is smaller, not larger, than an adult. An infant's
trachea has more surrounding soft tissue than an adult, which makes them more susceptible to
obstruction. The location of an infant's trachea does not make airway obstruction more likely.
It is the smaller lumen of the infant's trachea that can affect air flow.
PTS: 1 REF: p. 10 OBJ: 5
NAT: Client Needs: Physiological Integrity: Physiological Adaptation
TOP: Chapter 1: Chip Green: Bronchiolitis BLM: Cognitive Level: Understand
, 8. A nurse is preparing a class on infant wellness for parents at a community center. The parents
have infants aged 2 to 4 months. Which information should the nurse include in the class?
Select all that apply.
A. TdaP vaccine
B. Circumcision care
C. Hearing screening
D. Developmental milestones
E. Varicella vaccine
F. DTaP vaccine
ANS: D, F
Rationale: At 2-4 months of age, infants should receive their 1st and 2nd doses of the
diphtheria, tetanus, and pertussis (DTaP) vaccine. The nurse should also provide information
on expected developmental milestones. Newborn teaching includes circumcision care and
hearing screening. The varicella vaccine is not given until 12 months of age. The TdaP
vaccine, which has a dose of tetanus, and a reduced dose of the diphtheria and pertussis, is
given to children 7 years and older.
PTS: 1 REF: p. 3 OBJ: 2
NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter 1: Chip Green: Bronchiolitis BLM: Cognitive Level: Apply
9. A 4-month-old male i n f a Nn tUi R
s sSeI
enNiG
n-thTeEeS
mTerB
geAnNcyKr.oCOMwith clinical manifestations of
om
moderate respiratory distress including nasal stuffiness, nasal flaring, tachypnea, and grunting.
The infant's health history includes birth at 34 weeks' gestation, a temperature of 100.3°F
(37.9°C) and a cough for 2 days. Based on this information, the triage nurse suspects the
infant has developed which condition?
A. Bronchiolitis
B. Bronchitis
C. Croup
D. Tuberculosis
ANS: A
Rationale: Based on the infant's age, gender, gestational age at birth, and symptoms, the nurse
would suspect bronchiolitis. The infant's age, gender, gestational age at birth are all risk
factors for respiratory syncytial virus (RSV), which is the primary causal pathogen of
bronchiolitis. Croup causes inflammation of the larynx and trachea resulting in a barking
cough that occurs primarily at night; prematurity is not a risk factor for croup. Bronchitis
often occurs with an upper respiratory infection; a dry cough and fever may be present, but
respirations remain unlabored. Tuberculosis in children is usually associated with those
considered high risk (i.e., infected with HIV, exposed to family members with the disease).
PTS: 1 REF: p. 10 OBJ: 6
NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential
TOP: Chapter 1: Chip Green: Bronchiolitis BLM: Cognitive Level: Analyze
10. An infant is being treated for bronchiolitis. The infant's parent asks the nurse why this
condition has such an adverse effect on the infant's breathing. The nurse's response is based on
which fact?
A. Infants are obligate mouth breathers and have smaller tongues.
B. Infants have cylindrical tracheas and longer necks than adults.
C. Infants have a cartilaginous trachea and smaller bronchi than adults.
D. Infants have a smaller number of bronchioles and alveoli than adults.
ANS: C
Rationale: Newborns are obligate nose breathers until about 4 weeks of age; thereafter, infants
, can breathe through their mouths and nose (as long as the nares are patent). Infants have larger
tongues in relation to their mouths. Infants have shorter necks than adults; adults have a
larynx that is more cylindrical; the infant's larynx has more of a funnel shape than an adult.
PTS: 1 REF: p. 12 OBJ: 3
NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter 1: Chip Green: Bronchiolitis BLM: Cognitive Level: Apply
11. A parent brings the infant in for a wellness visit. During the visit, the parent tells the nurse "I
remember our conversation about me stopping smoking. I have cut down a lot and only smoke
outside on the porch." What is the best response for the nurse to make?
A. "I am glad to hear about the changes you have made. Keep up the good work!"
B. "You should stop smoking completely! You are still putting your baby at risk."
C. "It is not enough to just smoke outside. The smoke is still in your clothes when you
come inside."
D. "I am glad to hear about these positive changes. However, we need to talk about
this more."
ANS: D
Rationale: It is important for the nurse to acknowledge the positive changes that were made,
as well as the changes that are still needed. Even though the parent has cut down on the
amount of smoking and has stopped smoking in the house, the infant is still at risk for
thirdhand smoke (smoke and nicotine particles on the parent's clothing). The other statements
either solely praise the parent for the changes made or point out what still needs to be done.
And one is judgmental. None of those statements are therapeutic in nature.
PTS: 1 REF: p. 2 OBJ: 2
NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter 1: Chip Green: Bronchiolitis BLM: Cognitive Level: Analyze
12. A nurse is reviewing the health records of several 4-month-old infants who were seen in the
pediatric office today. Which infant behavior will require referral for further evaluation of
growth and development?
A. Reaches for nearby objects
B. Unable to support head
C. Cannot sit without assistance
D. Rolls from prone to supine position
ANS: B
Rationale: An infant at 4 months of age who cannot support his or her head should be referred
for evaluation. A 4-month-old infant should be able to reach for objects of interest and should
be able to roll from a prone to a supine position. A 4-month-old infant is not able to sit alone
without support.
PTS: 1 REF: p. 3 OBJ: 1
NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter 1: Chip Green: Bronchiolitis BLM: Cognitive Level: Analyze
, 13.
A 4-month-old infant is admitted with a diagnosis of bronchiolitis. The nurse writes the above
admission note. Based on the assessment findings, what inference can the nurse make about
the infant's initial plan of care?
A. Antibiotics will be started and the infant will be closely monitored overnight.
B. The infant will be intubated and transferred to the intensive care nursery.
C. Supplemental oxygen will be administered and nasopharyngeal suctioning
performed.
D. Intravenous fluids will be administered and the mother will be encouraged to feed
the infant as tolerated.
ANS: C
Rationale: The initial plan of care will focus on maintaining a patent airway and improving
gas exchange. Nasopharyngeal suctioning and administration of supplemental oxygen will
achieve that goal. Intravenous fluids and feedings as tolerated will be part of the plan of care
but not initially. Antibiotics are not recommended as part of the treatment for bronchiolitis
because research has shown them not to affect outcomes. There is no indication as yet to
intubate the infant or transfer to the intensive care nursery. If measures to clear the airway and
supplemental oxygen do not improve ventilation, then intubation might be considered.
PTS: 1 REF: p. 12 OBJ: 7
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter 1: Chip Green: Bronchiolitis BLM: Cognitive Level: Analyze
14. A 4-month-old infant has been admitted for moderate to severe respiratory distress secondary
to bronchiolitis. The infant has been suctioned, placed on oxygen via nasal cannula at 3 liters
per minute, and is receiving IV fluid at 20 milliliters per hour via pump. After an hour, the
infant's O2 saturation has increased from 86% to 92%. What action should the nurse take
based on this assessment?
Edition by Tagher
Chapter 01: Chip Jones: Bronchiolitis
1. A nurse is providing care for a 4-month-old infant at the pediatric clinic. During the
assessment the nurse should expect that the infant has reached which developmental
milestone(s)? Select all that apply.
A. Uses pincer grasp to pick up items
B. Can roll over from front onto back
C. Pulls self up to a standing position
D. Recognizes family members' faces
E. Pushes self up on arms from a prone position
F. Sits with support
ANS: B, D, E, F
Rationale: At 4 months of age, an infant is able to roll over from prone to supine position,
push the head/chest up on arms from a prone position, sit with support and recognize the faces
of close family members. The use of the pincer grasp and the ability to pull self up to a
standing position are expected at 10 months of age.
PTS: 1 REF: p. 4 OBJ: 1
NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter 1: Chip Green: Bronchiolitis BLM: Cognitive Level: Understand
2. A nurse is assessing a 3-month-old infant during a pediatric clinic visit. The nurse believes the
infant is demonstrating early manifestations of respiratory distress. Which clinical
manifestation(s) should the nurse document? Select all that apply.
, A. Bradycardia
B. Acrocyanosis
C. Intercostal retractions
D. Nasal congestion
E. Tachypnea
ANS: D, E
Rationale: Early signs of respiratory distress in an infant include fussiness, nasal congestion,
tachypnea and no interest in feeding. Intercostal retractions are signs of moderate distress;
bradycardia can be seen with severe respiratory distress. Acrocyanosis, in and of itself, is not
a sign of respiratory distress as it can be caused by poor circulation and cold extremities.
PTS: 1 REF: p. 8 OBJ: 4
NAT: Client Needs: Physiological Integrity: Physiological Adaptation
TOP: Chapter 1: Chip Green: Bronchiolitis BLM: Cognitive Level: Apply
3. A nurse is caring for an infant newly admitted for suspected bronchiolitis. The infant's parent
is very upset and states "I am so worried about my infant. What can you do to help my
infant?" What is the nurse's best response?
A. "There is no need to worry; we care for cases like this all the time."
B. "I know this is hard for you but do not worry. We will be able to discharge your
infant in a few days."
C. "No worries; having you hold the infant is very helpful. The infant will be back at
home in no time."
D. "I know it is difficult to see your infant like this. We will suction your infant and
give oxygen to make the infant comfortable.
ANS: D
Rationale: The option that states that it is difficult to see the infant like this is the only
response that explains to the parent what the nurse can do to help the infant and acknowledges
the parent's concern. The remaining options recognize the parent's concern but do not answer
the parent's question.
PTS: 1 REF: p. 10 OBJ: 7
NAT: Client Needs: Psychosocial Integrity
TOP: Chapter 1: Chip Green: Bronchiolitis BLM: Cognitive Level: Apply
4. A 3-month-old infant is hospitalized with a diagnosis of bronchiolitis. The nurse is creating a
plan of care for the infant. Which intervention is a priority?
A. Provide parental teaching on the antibiotics the infant will need to take at home.
B. Administer oxygen to maintain the infant's oxygen saturation at or above 92%.
C. Allow the parents to remain by the infant's side throughout the hospitalization.
D. Keep the infant NPO until the condition has resolved.
ANS: B
Rationale: Therapeutic management of bronchiolitis includes the administration of oxygen to
maintain O2 saturation at 92% or higher. Current evidence shows that antibiotics do not
improve outcomes in the treatment of bronchiolitis. Infants with bronchiolitis are encouraged
to feed as tolerated to maintain nutrition and fluid balance. While it is important for the
parents to be allowed to remain at the infant's side, it is not the priority.
PTS: 1 REF: p. 14 OBJ: 7
NAT: Client Needs: PhysiN
olU
ogRicSalIIN
ntG
eg-
r iT
t yE
: PShT
ysBioAloNgK
ic.
al C
AOdaMptation
TOP: Chapter 1: Chip Green: Bronchiolitis BLM: Cognitive Level: Apply
5.
, A nurse is caring for an infant admitted with a diagnosis of bronchiolitis. The nurse completes
an assessment with the above findings. What is the nurse's priority in providing care to this
infant?
A. Providing adequate fluids
B. Initiating tube feedings
C. Administering oxygen
D. Administering antipyretics
ANS: C
Rationale: The priority in providing care for this infant is to administer oxygen to increase the
O2 saturation to 92% or higher. Providing the infant adequate fluids and administering
antipyretics is also important, but these actions are not the priority. There is no need to initiate
tube feedings for this client.
PTS: 1 REF: p. 11 OBJ: 8
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter 1: Chip Green: Bronchiolitis BLM: Cognitive Level: Analyze
6. An infant is diagnosed with bronchiolitis. The nurse is teaching the parent of how to use a
bulb suction to clear the infant's airway. What is the best way for the nurse to evaluate the
effectiveness of the teaching?
A. Guide the parent step by step through the procedure.
B. Have the parent verbalize each step of the procedure.
C. Observe the parent as he/she suctions the infant.
D. Provide the parent with written instructions of the procedure.
ANS: C
Rationale: The best way N foUrR
thS
eInuNrG
se-tT
oEevSaT
luB
atA
eNthKe.pC
arO
enMt's understanding of the teaching is
for the parent to give a return demonstration so the nurse can observe the parent's technique.
Having the parent verbalize the steps of the procedure will only tell the nurse that the parent
remembered what was said; this does not assess the parent's ability to perform the procedure.
Guiding the parent step by step or providing the parent with written instructions will not help
the nurse evaluate the parent's understanding.
PTS: 1 REF: p. 11 OBJ: 8
NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter 1: Chip Green: Bronchiolitis BLM: Cognitive Level: Apply
7. Which statement best describes the difference between an infant's respiratory tract and that of
an adult?
A. The infant's respiratory tract has more alveoli than the adult.
B. The trachea and bronchi have smaller lumens in the infant.
C. Because of the location of an infant's trachea airway obstruction is less likely.
D. Adults have more soft tissue surrounding the trachea than infants.
ANS: B
Rationale: The infant's respiratory tract has smaller bronchi and fewer alveoli than adults. An
infant's neck is shorter, and the trachea lumen is smaller, not larger, than an adult. An infant's
trachea has more surrounding soft tissue than an adult, which makes them more susceptible to
obstruction. The location of an infant's trachea does not make airway obstruction more likely.
It is the smaller lumen of the infant's trachea that can affect air flow.
PTS: 1 REF: p. 10 OBJ: 5
NAT: Client Needs: Physiological Integrity: Physiological Adaptation
TOP: Chapter 1: Chip Green: Bronchiolitis BLM: Cognitive Level: Understand
, 8. A nurse is preparing a class on infant wellness for parents at a community center. The parents
have infants aged 2 to 4 months. Which information should the nurse include in the class?
Select all that apply.
A. TdaP vaccine
B. Circumcision care
C. Hearing screening
D. Developmental milestones
E. Varicella vaccine
F. DTaP vaccine
ANS: D, F
Rationale: At 2-4 months of age, infants should receive their 1st and 2nd doses of the
diphtheria, tetanus, and pertussis (DTaP) vaccine. The nurse should also provide information
on expected developmental milestones. Newborn teaching includes circumcision care and
hearing screening. The varicella vaccine is not given until 12 months of age. The TdaP
vaccine, which has a dose of tetanus, and a reduced dose of the diphtheria and pertussis, is
given to children 7 years and older.
PTS: 1 REF: p. 3 OBJ: 2
NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter 1: Chip Green: Bronchiolitis BLM: Cognitive Level: Apply
9. A 4-month-old male i n f a Nn tUi R
s sSeI
enNiG
n-thTeEeS
mTerB
geAnNcyKr.oCOMwith clinical manifestations of
om
moderate respiratory distress including nasal stuffiness, nasal flaring, tachypnea, and grunting.
The infant's health history includes birth at 34 weeks' gestation, a temperature of 100.3°F
(37.9°C) and a cough for 2 days. Based on this information, the triage nurse suspects the
infant has developed which condition?
A. Bronchiolitis
B. Bronchitis
C. Croup
D. Tuberculosis
ANS: A
Rationale: Based on the infant's age, gender, gestational age at birth, and symptoms, the nurse
would suspect bronchiolitis. The infant's age, gender, gestational age at birth are all risk
factors for respiratory syncytial virus (RSV), which is the primary causal pathogen of
bronchiolitis. Croup causes inflammation of the larynx and trachea resulting in a barking
cough that occurs primarily at night; prematurity is not a risk factor for croup. Bronchitis
often occurs with an upper respiratory infection; a dry cough and fever may be present, but
respirations remain unlabored. Tuberculosis in children is usually associated with those
considered high risk (i.e., infected with HIV, exposed to family members with the disease).
PTS: 1 REF: p. 10 OBJ: 6
NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential
TOP: Chapter 1: Chip Green: Bronchiolitis BLM: Cognitive Level: Analyze
10. An infant is being treated for bronchiolitis. The infant's parent asks the nurse why this
condition has such an adverse effect on the infant's breathing. The nurse's response is based on
which fact?
A. Infants are obligate mouth breathers and have smaller tongues.
B. Infants have cylindrical tracheas and longer necks than adults.
C. Infants have a cartilaginous trachea and smaller bronchi than adults.
D. Infants have a smaller number of bronchioles and alveoli than adults.
ANS: C
Rationale: Newborns are obligate nose breathers until about 4 weeks of age; thereafter, infants
, can breathe through their mouths and nose (as long as the nares are patent). Infants have larger
tongues in relation to their mouths. Infants have shorter necks than adults; adults have a
larynx that is more cylindrical; the infant's larynx has more of a funnel shape than an adult.
PTS: 1 REF: p. 12 OBJ: 3
NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter 1: Chip Green: Bronchiolitis BLM: Cognitive Level: Apply
11. A parent brings the infant in for a wellness visit. During the visit, the parent tells the nurse "I
remember our conversation about me stopping smoking. I have cut down a lot and only smoke
outside on the porch." What is the best response for the nurse to make?
A. "I am glad to hear about the changes you have made. Keep up the good work!"
B. "You should stop smoking completely! You are still putting your baby at risk."
C. "It is not enough to just smoke outside. The smoke is still in your clothes when you
come inside."
D. "I am glad to hear about these positive changes. However, we need to talk about
this more."
ANS: D
Rationale: It is important for the nurse to acknowledge the positive changes that were made,
as well as the changes that are still needed. Even though the parent has cut down on the
amount of smoking and has stopped smoking in the house, the infant is still at risk for
thirdhand smoke (smoke and nicotine particles on the parent's clothing). The other statements
either solely praise the parent for the changes made or point out what still needs to be done.
And one is judgmental. None of those statements are therapeutic in nature.
PTS: 1 REF: p. 2 OBJ: 2
NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter 1: Chip Green: Bronchiolitis BLM: Cognitive Level: Analyze
12. A nurse is reviewing the health records of several 4-month-old infants who were seen in the
pediatric office today. Which infant behavior will require referral for further evaluation of
growth and development?
A. Reaches for nearby objects
B. Unable to support head
C. Cannot sit without assistance
D. Rolls from prone to supine position
ANS: B
Rationale: An infant at 4 months of age who cannot support his or her head should be referred
for evaluation. A 4-month-old infant should be able to reach for objects of interest and should
be able to roll from a prone to a supine position. A 4-month-old infant is not able to sit alone
without support.
PTS: 1 REF: p. 3 OBJ: 1
NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter 1: Chip Green: Bronchiolitis BLM: Cognitive Level: Analyze
, 13.
A 4-month-old infant is admitted with a diagnosis of bronchiolitis. The nurse writes the above
admission note. Based on the assessment findings, what inference can the nurse make about
the infant's initial plan of care?
A. Antibiotics will be started and the infant will be closely monitored overnight.
B. The infant will be intubated and transferred to the intensive care nursery.
C. Supplemental oxygen will be administered and nasopharyngeal suctioning
performed.
D. Intravenous fluids will be administered and the mother will be encouraged to feed
the infant as tolerated.
ANS: C
Rationale: The initial plan of care will focus on maintaining a patent airway and improving
gas exchange. Nasopharyngeal suctioning and administration of supplemental oxygen will
achieve that goal. Intravenous fluids and feedings as tolerated will be part of the plan of care
but not initially. Antibiotics are not recommended as part of the treatment for bronchiolitis
because research has shown them not to affect outcomes. There is no indication as yet to
intubate the infant or transfer to the intensive care nursery. If measures to clear the airway and
supplemental oxygen do not improve ventilation, then intubation might be considered.
PTS: 1 REF: p. 12 OBJ: 7
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter 1: Chip Green: Bronchiolitis BLM: Cognitive Level: Analyze
14. A 4-month-old infant has been admitted for moderate to severe respiratory distress secondary
to bronchiolitis. The infant has been suctioned, placed on oxygen via nasal cannula at 3 liters
per minute, and is receiving IV fluid at 20 milliliters per hour via pump. After an hour, the
infant's O2 saturation has increased from 86% to 92%. What action should the nurse take
based on this assessment?
