NCLEX 10000 Infant Midterm Exam
Questions And Already Passed Answers.
Which of the following nursing interventions is most important postoperatively for an infant
who has received a ventriculoperitoneal shunt?
a) Allowing the infant to rest undisturbed.
b) Providing age-appropriate diversionary activities.
c) Initiating oral feedings.
d) Monitoring intake and output. - Answer Monitoring intake and output.
Correct
Explanation:
In the postoperative period, intake and output are carefully monitored to prevent fluid overload
that could lead to increased intracranial pressure.
When assessing a 4-month-old infant diagnosed with possible intussusception, the nurse should
expect the parent to relate what information about the infant's crying and episodes of pain?
a) intermittent while being held in the parent's arms
b) intermittent with knees drawn to the chest
c) shrill during ingestion of solids
d) constant accompanied by leg extension - Answer intermittent with knees drawn to the
chest
Correct
Explanation:
The infant with intussusception experiences acute episodes of colic-like abdominal pain.
Typically, the infant screams and draws the knees to the chest. Between these episodes of acute
abdominal pain, the infant appears comfortable and normal.
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 (3,005 g), and his current weight is 7 lb, 4
oz (3,289 g), falling below the 5th percentile on a standard growth chart. Which of the following
data should the nurse identify as the priority?
, d) Family dynamics. - Answer Feeding pattern.
Correct
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.
Three weeks after the application of a spica cast following surgery, the mother calls the nurse
because the infant's toes are swollen and cool to the touch. The nurse should instruct the
mother to do which of the following?
a) Have the child fitted for a larger cast.
b) Put more cotton wadding to line the casting.
c) Inspect the area for an infection.
d) Place the child's legs in a lowered position. - Answer Have the child fitted for a larger cast.
Correct
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.
An 8-month-old infant is admitted to the pediatric unit following a fall from his high chair. The
child is awake, alert, and crying. The nurse should know that a brain injury is more severe in
children because of:
a) a slightly thicker cranium
b) intracranial hypotension
c) cerebral hyperemia
d) increased myelination - Answer cerebral hyperemia
Correct
Questions And Already Passed Answers.
Which of the following nursing interventions is most important postoperatively for an infant
who has received a ventriculoperitoneal shunt?
a) Allowing the infant to rest undisturbed.
b) Providing age-appropriate diversionary activities.
c) Initiating oral feedings.
d) Monitoring intake and output. - Answer Monitoring intake and output.
Correct
Explanation:
In the postoperative period, intake and output are carefully monitored to prevent fluid overload
that could lead to increased intracranial pressure.
When assessing a 4-month-old infant diagnosed with possible intussusception, the nurse should
expect the parent to relate what information about the infant's crying and episodes of pain?
a) intermittent while being held in the parent's arms
b) intermittent with knees drawn to the chest
c) shrill during ingestion of solids
d) constant accompanied by leg extension - Answer intermittent with knees drawn to the
chest
Correct
Explanation:
The infant with intussusception experiences acute episodes of colic-like abdominal pain.
Typically, the infant screams and draws the knees to the chest. Between these episodes of acute
abdominal pain, the infant appears comfortable and normal.
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 (3,005 g), and his current weight is 7 lb, 4
oz (3,289 g), falling below the 5th percentile on a standard growth chart. Which of the following
data should the nurse identify as the priority?
, d) Family dynamics. - Answer Feeding pattern.
Correct
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.
Three weeks after the application of a spica cast following surgery, the mother calls the nurse
because the infant's toes are swollen and cool to the touch. The nurse should instruct the
mother to do which of the following?
a) Have the child fitted for a larger cast.
b) Put more cotton wadding to line the casting.
c) Inspect the area for an infection.
d) Place the child's legs in a lowered position. - Answer Have the child fitted for a larger cast.
Correct
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.
An 8-month-old infant is admitted to the pediatric unit following a fall from his high chair. The
child is awake, alert, and crying. The nurse should know that a brain injury is more severe in
children because of:
a) a slightly thicker cranium
b) intracranial hypotension
c) cerebral hyperemia
d) increased myelination - Answer cerebral hyperemia
Correct
