Chapter 35 Note: Thousands of additional practice questions are available on the enclosed companion CD. 2. A family has decided to withhold “extraordinary care” for a newborn with severe abnormalities. How should the nurse interpret this decision? 3. A nurse is planning an initial home care visit to a mother who gave birth to a high-risk infant. For what time of day should the nurse schedule the visit for it to be most productive? 1. When the husband is out of the home. 2. At a time the mother is feeding the infant. 3. At a time that is convenient for the family. 4. What is the first action a nurse should take before administering a tube feeding to an infant? 1. Irrigate the tube with water. 2. Offer a pacifier to the infant. 3. Slowly instill 10 mL of formula. 5. Which nursing intervention provides the most support to the parents of an infant with an obvious physical anomaly? 1. Encourage them to express their concerns. 2. Discourage them from talking about their baby. 3. Assure them not to worry because the anomaly can be repaired. 4. Show them postoperative photographs of infants who had similar anomaly. 6. When picked up by a parent or the nurse, an 8-month-old infant screams and seems to be in pain. After observing this behavior, what should the nurse discuss with the parent? 1. Accidents and the importance of their prevention 2. Limiting play time with other children in the family 3. Any other behaviors that the parent may have noticed 4. Food and specific vitamins that should be given to infants 7. A 1-week-old infant has been in the pediatric unit for 18 hours following placement of a spica cast. The nurse observes a respiratory rate of fewer than 24 breaths/min. No other changes are noted. Because the infant is apparently well, the nurse does not report or documentation the slow respiratory rate. Several hours later, the infant experiences severe respiratory distress and emergency care is necessary. What should be considered if legal action is taken? 1. Most infants’ respirations are slow when they are uncomfortable. 2. The respirations of young infants are irregular, so a drop in rate is unimportant. 3. Vital signs that are outside the expected parameters are significant and should be documented. 4. The respiratory tract of young infants is underdeveloped, and their respiratory rate is not significant. 1. Give smaller, more frequent feedings. 2. Burp frequently when giving a feeding. 3. Place a warm heating pad on the abdomen. 4. Offer warm, sweetened tea when crying begins. 10. What nursing intervention best meets a major developmental need of a newborn in the immediate postoperative period? 1. Giving a pacifier to the infant 2. Putting a mobile over the infant’s crib 3. Providing the infant with a soft, cuddly toy 12. A parent and 3-month-old infant are visiting the well-baby clinic for a routine examination. What should the nurse include in the accident prevention teaching plan? 1. Remove small objects from the floor. 2. Cover electric outlets with safety plugs. 3. Remove toxic substances from low areas. 13. A nurse is teaching a parent how to prevent accidents while caring for a 6-month-old infant. What ability should be emphasized about the infant’s motor development? 14. A 7-month-old girl is to be catheterized to obtain a sterile urine specimen. One of the infant’s parents expresses fear that this procedure may traumatize the baby psychologically. How should the nurse provide reassurance? 1. The fear is justified and the nurse should obtain a “clean catch” specimen. 2. Parents have a right to refuse the catheterization and the concerns are realistic. 3. Although the concern is appropriate, the need for a sterile specimen is the priority. 4. The procedure is uncomfortable, but there should not be a damaging long-term effect. 15. A nurse is assessing the oral cavity of a 6-month-old infant. The parent asks which teeth will erupt first. How should the nurse respond? 16. A nurse is teaching a class of new parents about how to position their infants during the first few weeks of life. Which position is safest? 17. A parent arrives in the emergency clinic with a 3-month-old baby who says, “My baby stopped breathing for a while.” The infant continues to have difficulty breathing, with prolonged periods of apnea. Which assessment data should alert the nurse to suspect shaken baby syndrome (SBS)? 1. Birth occurred before 32 weeks’ gestation 2. Lack of stridor and adventitious breath sounds 3. Previous episodes of apnea lasting 10 to 15 seconds 18. Parents of a sick infant talk with a nurse about their baby. One parent says, “I am so upset; I didn’t realize our baby was ill.” What major indication of illness in an infant should the nurse explain to the parent? 19. A newborn is admitted to the neonatal intensive care unit (NICU) with choanal atresia. Which part of the infant’s body should the nurse assess? 20. What behavior does the nurse anticipate while feeding a newborn with choanal atresia? 22. What is the nurse’s priority intervention when preparing for admission of a child with acute laryngotracheobronchitis? 1. Pad the side rails of the crib. 2. Arrange for a quiet, cool room. 3. Place a tracheotomy set at the bedside. 23. What should be the nurse’s priority action when caring for a child with acute laryngotracheobronchitis? 1. Initiate measures to reduce fever. 2. Ensure delivery of humidified oxygen. 3. Provide support to reduce apprehension. 24. A 3-month-old infant has been hospitalized with respiratory syncytial virus (RSV). What is the priority intervention? 1. Administering an antiviral agent 2. Clustering care to conserve energy 3. Offering oral fluids to promote hydration 26. A child is admitted to the hospital with pneumonia. What is the priority need that must be included in the nursing plan of care for this child? 27. A 6-month-old infant is brought to the emergency department in severe respiratory distress. A diagnosis of respiratory syncytial virus (RSV) is made and the infant is admitted to the pediatric unit. What should be included in the nursing plan of care? 1. Place in a warm, dry environment. 2. Allow parents and siblings to visit. 3. Maintain standard and contact precautions. 28. An infant is admitted to the neonatal intensive care unit (NICU) with exstrophy of the bladder. What covering should the nurse use to protect the exposed area? 29. An additional defect is associated with exstrophy of the bladder. For what anomaly should the nurse assess the infant? 30. A nurse is caring for an infant born with exstrophy of the bladder. What does the nurse determine is the greatest risk for this infant? 31. A home care nurse is visiting a family for the first time. The 4-week-old infant had surgery for exstrophy of the bladder and creation of an ileal conduit soon after birth. When the nurse arrives, the mother appears tired and the baby is crying. After an introduction, which is the most appropriate statement by the nurse? 1. “Tell me about your daily routine.” 2. “You look tired. Is everything all right?” 3. “When was the last time the baby had a bottle?” 32. The nurse is teaching a parent group about the reason for adhering to the immunization schedule. What complication of mumps is important for adolescents to avoid? 33. A nurse is performing a physical examination on an infant with Down syndrome. For what anomaly should the nurse assess the child? 34. A parent tells the nurse, “My 9-month-old baby no longer has the same strong grasp that was present at birth and no longer acts startled by loud noises.” How should the nurse explain these changes in behavior? 1. “I will check these responses before deciding how to proceed.” 2. “Failure of these responses may be related to a developmental delay.” 3. “Additional sensory stimulation is needed to aid in the return of these responses.” 4. “These responses are replaced by voluntary activity at about five months of age.” 35. The nurse is teaching a group of parents about the side effects of the immunization vaccines. Which sign should the nurse include when talking about an infant receiving the Haemophilus influenzae (Hib) vaccine? 37. An infant who has had diarrhea for 3 days is admitted in a lethargic state and is breathing rapidly. The parent states that the baby has been ingesting formula, although not as much as usual, and cannot understand the sudden change. What explanation should the nurse give the parent? 1. Cellular metabolism is unstable in young children. 2. The proportion of water in the body is less than in adults. 3. Renal function is immature in children until they reach school age. 4. The extracellular fluid requirement per unit of body weight is greater than in adults. 38. When explaining the occurrence of febrile seizures to a parents’ class, what information should the nurse include? 1. They may occur in minor illnesses. 2. The cause is usually readily identified. 3. They usually do not occur during the toddler years. 4. The frequency of occurrence is greater in females than males. 39. A parent tells the nurse in the emergency department, “My 3-year-old has had a fever for several days and has been vomiting.” After instituting ordered measures to reduce the fever, what nursing action is most important? 40. The nurse observes that a 3-year-old child in a crib has a clamped jaw and is having a tonic-clonic seizure. What is the priority nursing responsibility at this time? 41. A child sitting on a chair in a playroom starts to have a tonic-clonic seizure with a clenched jaw. What is the nurse’s best initial action? 43. An infant is diagnosed with communicating hydrocephalus. The parents ask for clarification of the health care provider’s explanation of their baby’s problem. How should the nurse respond? 1. “Too much spinal fluid is produced within the spaces (ventricles) of the brain.” 2. “The flow of spinal fluid through the brain cells does not empty effectively into the spinal cord.” 3. “The spinal fluid is prevented from adequate absorption by a blockage in the spaces (ventricles) of the brain.” 4. “There is a part of the brain surface that usually absorbs spinal fluid after its production that is not functioning adequately.” 44. A 6-week-old infant and the mother arrive in the emergency department via 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? 1. Identify the problems that they will be facing related to the loss of the infant. 2. Include the infant’s siblings in the events and grieving following the infant’s death. 3. Seek out other families who have lost infants to SIDS and receive support from them. 4. Accept that there was nothing that they should have done to prevent the infant’s death. 45. What should be included in the nursing care of an infant with increased intracranial pressure? 1. Weigh daily before feeding. 2. Elevate the head higher than the hips. 3. Check the reflexes at regular intervals. 46. The parents of an infant who just had a ventriculoperitoneal shunt inserted for hydrocephalus are concerned about the prognosis. What information should the nurse give the parents? 1. The prognosis is excellent and the valve is permanent. 2. The shunt may need to be revised as the child grows older. 3. If any brain damage has occurred, it is irreversible even after the first year of life. 4. Hydrocephalus usually is self-limiting by 2 years of age, and then the shunt is removed. 47. An infant who was born with a meningomyelocele develops hydrocephalus. A ventriculoperitoneal shunt is inserted. What nursing intervention is essential in this infant’s care during the first 24 hours after surgery? 1. Placing in high-Fowler position 2. Administering the prescribed sedative 3. Positioning on the same side as the shunt 48. The discharge of a newborn with a surgically repaired myelomeningocele is anticipated at about 2 weeks of age. What teaching should the nurse include when preparing the parents for the discharge? 1. Demonstration of restrictive positions to prevent the infant from turning 2. Discussion about the need to limit the infant’s fluid intake to formula only 3. Instructions on how to do passive range-of-motion exercises to the infant’s lower extremities 4. Explanation of the need to provide the infant with a quiet environment to reduce external stimuli 50. A nurse in the pediatric clinic is assessing an infant who had a revision of a ventriculoperitoneal shunt. What clinical finding alerts the nurse that intracranial pressure has increased? 51. The parents of an infant who has had a surgical repair of a myelomeningocele express concern about skin care and ask what they can do to avoid problems. The nurse should teach the parents that their infant: 1. will require long-term multidisciplinary follow-up care. 2. should take prophylactic antibiotic therapy indefinitely. 3. must be kept dry by applying powder after each diaper change. 4. does not need anything more than routine cleansing and diaper changes. 52. What is the primary nursing intervention for an infant with a myelomeningocele before surgical correction? 53. An infant with a myelomeningocele is admitted to the pediatric intensive care unit (PICU). While the infant is awaiting surgical correction of the defect, what is the most appropriate nursing intervention? 2. Placing the infant in the prone position 3. Performing neurologic checks above the site of the lesion 4. Washing the area below the defect with a nontoxic antiseptic 54. After closure of a newborn’s myelomeningocele, what essential nursing intervention must be included in the plan of care? 55. A nurse is caring for an infant with bacterial meningitis. The parents ask how their baby could have contracted the illness. What does the nurse consider as the most likely route of transmission to the central nervous system (CNS)? 1. _____ Institute respiratory isolation. 2. _____ Assist with a lumbar puncture. 3. _____ Insert a circulatory access device. 4. _____ Administer prescribed antibiotics. 57. For how long should a nurse maintain isolation of a child with bacterial meningitis? 1. For 12 hours after admission 2. Until the cultures are negative 3. Until antibiotic therapy is completed 58. A 1-year-old infant has been admitted with a tentative diagnosis of bacterial meningitis. A lumbar puncture is performed to confirm the diagnosis. What laboratory report of the spinal fluid supports this diagnosis? 59. A nurse is caring for a child with meningococcal meningitis. What clinical finding does the nurse expect when performing a physical assessment? 61. What does a nurse determine is the most serious complication of meningitis in young children? 62. The nurse observes that an infant has asymmetric gluteal folds. For which disorder should the nurse perform a focused assessment? 63. A 3-month-old infant with severe developmental dysplasia of the hip has a hip spica cast applied. What should the nurse teach the parents to prevent a serious complication? 64. A 4-month-old infant had a spica cast applied. What should the nurse include in the discharge instructions to the parents? 1. Obtain a specially designed car seat. 2. Keep diapers on to prevent soiling of the cast. 3. Change the infant’s position every eight hours. 4. Use the bar between the infant’s legs to change positions. 65. What procedure should a nurse use when elevating the head of an infant in a spica cast? 1. Change this position after an hour. 2. Place pillows under the shoulders. 3. Pad the edge of the cast with folded diapers. 66. A nurse is caring for a 3-month-old infant who is diagnosed with congenital hypothyroidism. What should the parents be told of the probable effect on the infant’s future if treatment is not begun immediately? 67. At a visit to the well-baby clinic, the parents are upset because their 9-month-old infant has a severe diaper rash; one parent wants to know how to treat it and prevent it from recurring. What cause of diaper dermatitis should the nurse include when answering the parent’s question? 68. A parent brings a 2-week-old infant to the clinic because the infant continually regurgitates. Chalasia, an incompetent cardiac sphincter, is suspected. What instructions should the nurse give the parent? 1. Keep the infant in an upright position after feedings. 2. Prevent the infant from crying for prolonged periods. 3. Keep the infant in the prone position following feedings. 4. Ensure that the infant drinks a full bottle of formula at each feeding. 69. A parent brings a 9-month-old infant to the pediatric clinic and asks about the introduction of new foods. What should the nurse suggest? 1. “Mix the pureed food with formula and offer it in a bottle.” 2. “Give the entire regular feeding and then introduce the new food.” 3. “Offer a new food every day until one is accepted and then offer it again.” 4. “Give a small amount of formula and then offer the new food while still hungry.” 70. What should nursing care for an infant after the surgical repair of a cleft lip include? 71. A nurse who is caring for an infant with a cleft lip is concerned about preventing an infection. Why does the cleft lip predispose the infant to infection? 1. Waste products accumulate along the defect. 2. There is inadequate circulation in the defective area. 3. Nutrition is inadequate because of ineffective feeding. 4. Mouth breathing dries the oropharyngeal mucous membranes. 72. What should a nurse use to feed an infant born with a unilateral cleft lip and palate? 73. A parent of an 11-month-old infant who has a cleft palate asks the nurse why it was recommended that closure of the palate should be done before the age of 2. How should the nurse respond? 1. “After age 2 surgery is frightening and should be avoided if possible.” 2. “Eruption of the 2-year molars often complicates the surgical procedure.” 3. “As your child gets older, the palate gets wider and more difficult to repair.” 4. “Surgery should be performed before your child starts to use faulty speech patterns.” 2. _____ Maintaining a patent airway 3. _____ Assessing the infant’s hearing status 4. _____ Monitoring parenteral fluid infusions 75. An infant with hypertrophic pyloric stenosis (HPS) is admitted to the pediatric unit. What does the nurse expect when palpating the infant’s abdomen? 76. A nurse is caring for an infant with a tentative diagnosis of hypertrophic pyloric stenosis (HPS). What is most important for the nurse to assess? 77. Surgery to correct hypertrophic pyloric stenosis (HPS) is performed on a 3-week-old infant who had been formula-fed. Which postoperative feeding order is appropriate? 1. Thickened formula 24 hours after surgery 2. Withholding feedings for the first 24 hours 3. Regular formula feeding within 24 hours after surgery 4. Additional glucose feedings as desired after first 24 hours 78. Corrective surgery for hypertrophic pyloric stenosis (HPS) is completed, and the infant is returned to the pediatric unit with an IV infusion in place. What is the priority nursing action? 79. An infant had corrective surgery for hypertrophic pyloric stenosis (HPS). What should the nurse teach a parent to do immediately after a feeding to limit vomiting? 80. A newborn with an anorectal anomaly had an anoplasty performed. At the 2-week follow-up visit, a series of anal dilations are begun. What should the nurse recommend to the parents to help prevent the infant from becoming constipated? 81. A nurse is caring for an infant with phenylketonuria (PKU). What diet should the nurse anticipate will be ordered by the health care provider? 82. What should the nurse include in the teaching plan for parents of an infant diagnosed with phenylketonuria (PKU)? 1. Mental retardation occurs if PKU is untreated. 2. Testing for PKU is done immediately after birth. 3. Treatment for PKU includes lifelong medications. 83. The parents of a newborn with phenylketonuria (PKU) need help and support in adhering to specific dietary restrictions. They ask the nurse, “How long will our child have to be on this diet?” How should the nurse respond? 1. “We still are not sure; you should discuss this with your health care provider.” 2. “If your baby does well, foods containing protein can gradually be introduced.” 3. “Your child needs to be on this diet at least through adolescence and into adulthood.” 4. “This is a lifelong problem, and it is recommended that dietary restrictions must be continued.” 84. A nurse plans to discuss childhood nutrition with a group of parents whose children have Down syndrome in an attempt to minimize a common nutritional problem. What problem should be addressed? 86. A nurse is discussing the care of an infant with colic with the parents. What should the nurse explain is the cause of colicky behavior? 3. An allergic response to certain proteins in milk 4. A protective mechanism designed to eliminate foreign proteins 87. A 1-month-old infant is admitted to the pediatric unit with a tentative diagnosis of Hirschsprung disease (congenital aganglionic megacolon). What procedure does the nurse expect to be used to confirm the diagnosis?
Child Health Nursing
Review Questions with Answers and Rationales
Denotes alternate format question.
Nursing Care of Infants
1. The parents of a child call the clinic and tell the nurse that their child is irritable and has a 102° F temperature after having had a routine immunization. The clinic protocol indicates acetaminophen 15 mg/kg is to be administered every 4 to 6 hours. The child’s last weight was 9.6 kg. The parent states, “The bottle of acetaminophen says that there are 160 mg in 5 mL.” How much should the nurse tell the parent to administer for each dose? Record your answer using one decimal place.
8. What suggestions should a nurse give to a parent to help a 2-month-old infant who has colic? Select all that apply.
9. A nurse at the well-child clinic determines a 1-year-old infant’s length to be below what is expected. The current height is 28 inches, and the birth length was 20 inches. What should this infant’s current length be? Record your answer using a whole number.
11. What characteristics does a nurse expect infants and young children who have failure to thrive to exhibit? Select all that apply.
21. An infant is admitted to the pediatric intensive care unit (PICU) after open-heart surgery for the repair of a ventricular septal defect. Place these nurse assessments in order of priority.
25. The health care provider prescribes 375 mg ampicillin IV q6h for a 5-month-old with recurring respiratory infections. The drug is supplied as 500 mg of powder in a vial. The directions state to mix the powder with 1.8 mL diluent, which yields 250 mg/mL. How many milliliters should the nurse administer? Record your answer using one decimal place.
36. An infant is receiving parenteral therapy. The IV orders are 400 mL of D5W 0.45% sodium chloride to run over 8 hours. At what rate should the nurse maintain the hourly rate? Record your answer using a whole number.
42. A nurse is caring for a child with the diagnosis of meningitis. What clinical findings indicate an increase in intracranial pressure? Select all that apply.
49. An infant who had a revision of a ventriculoperitoneal shunt is diagnosed with meningitis from an infected shunt. What clinical manifestations support this conclusion? Select all that apply.
56. The nurse is admitting an 8-month-old infant to the hospital because bacterial meningitis is suspected. List in order of priority the nursing actions that should be taken.
60. A nurse is caring for a 2-year-old child with meningitis. For which clinical manifestations of increasing intracranial pressure should the nurse assess the child? Select all that apply.
74. An infant has a cleft lip and palate and is admitted to the hospital for a surgical repair. Place the nurse’s postoperative interventions in order of priority.
85. A nurse is caring for a 3-month-old infant whose abdomen is distended and whose vomitus is bile stained. The nurse suspects an intestinal obstruction. What clinical manifestations support this suspicion? Select all that apply.
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