Wong’s Nursing Care of Infants And Children 10th Edition by Marilyn J. Hockenberry, David Wilson  – Test Bank  

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INSTANT DOWNLOAD COMPLETE TEST BANK WITH ANSWERS

 

Wong’s Nursing Care of Infants and Children 10th Edition by Marilyn J. Hockenberry, David Wilson  – Test Bank

 

Sample  Questions

 

Chapter 05: Pain Assessment and Management in Children

 

MULTIPLE CHOICE

 

  1. Which is the most consistent and commonly used data for assessment of pain in infants?
a. Self-report
b. Behavioral
c. Physiologic
d. Parental report

 

 

ANS:  B

Behavioral assessment is useful for measuring pain in young children and preverbal children who do not have the language skills to communicate that they are in pain. Infants are not able to self-report. Physiologic measures are not able to distinguish between physical responses to pain and other forms of stress. Parental report without a structured tool may not accurately reflect the degree of discomfort.

 

DIF:    Cognitive Level: Understanding     REF:   p. 152

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. Children as young as age 3 years can use facial scales for discrimination. What are some suggested anchor words for the preschool age group?
a. “No hurt.”
b. “Red pain.”
c. “Zero hurt.”
d. “Least pain.”

 

 

ANS:  A

“No hurt” is a phrase that is simple, concrete, and appropriate to the preoperational stage of the child. Using color is complicated for this age group. The child needs to identify colors and pain levels and then choose an appropriate symbolic color. This is appropriate for an older child. Zero is an abstract construct not appropriate for this age group. “Least pain” is less concrete than “no hurt.”

 

DIF:    Cognitive Level: Applying              REF:   p. 154

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. What is an important consideration when using the FACES pain rating scale with children?
a. Children color the face with the color they choose to best describe their pain.
b. The scale can be used with most children as young as 3 years.
c. The scale is not appropriate for use with adolescents.
d. The FACES scale is useful in pain assessment but is not as accurate as physiologic responses.

 

 

ANS:  B

The FACES scale is validated for use with children ages 3 years and older. Children point to the face that best describes their level of pain. The scale can be used through adulthood. The child’s estimate of the pain should be used. The physiologic measures may not reflect more long-term pain.

 

DIF:    Cognitive Level: Applying              REF:   p. 154

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. What describes nonpharmacologic techniques for pain management?
a. They may reduce pain perception.
b. They usually take too long to implement.
c. They make pharmacologic strategies unnecessary.
d. They trick children into believing they do not have pain.

 

 

ANS:  A

Nonpharmacologic techniques provide coping strategies that may help reduce pain perception, make the pain more tolerable, decrease anxiety, and enhance the effectiveness of analgesics. The nonpharmacologic strategy should be matched with the child’s pain severity and be taught to the child before the onset of the painful experience. Tricking children into believing they do not have pain may mitigate the child’s experience with mild pain, but the child will still know the discomfort was present.

 

DIF:    Cognitive Level: Analyzing            REF:   pp. 163-164   TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. Which nonpharmacologic intervention appears to be effective in decreasing neonatal procedural pain?
a. Tactile stimulation
b. Commercial warm packs
c. Doing procedure during infant sleep
d. Oral sucrose and nonnutritive sucking

 

 

ANS:  D

Nonnutritive sucking attenuates behavioral, physiologic, and hormonal responses to pain. The addition of sucrose has been demonstrated to have calming and pain-relieving effects for neonates. Tactile stimulation has a variable effect on response to procedural pain. No evidence supports commercial warm packs as a pain control measure. With resulting increased blood flow to the area, pain may be greater. The infant should not be disturbed during the sleep cycle. It makes it more difficult for the infant to begin organization of sleep and awake cycles.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 165            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. A 6-year-old child has patient-controlled analgesia (PCA) for pain management after orthopedic surgery. The parents are worried that their child will be in pain. What should your explanation to the parents include?
a. The child will continue to sleep and be pain free.
b. Parents cannot administer additional medication with the button.
c. The pump can deliver baseline and bolus dosages.
d. There is a high risk of overdose, so monitoring is done every 15 minutes.

 

 

ANS:  C

The PCA prescription can be set for a basal rate for a continuous infusion of pain medication. Additional doses can be administered by the patient, parent, or nurse as necessary. Although the goal of PCA is to have effective pain relief, a pain-free state may not be possible. With a 6-year-old child, the parents and nurse must assess the child to ensure that adequate medication is being given because the child may not understand the concept of pushing a button. Evidence-based practice suggests that effective analgesia can be obtained with the parents and nurse giving boluses as necessary. The prescription for the PCA includes how much medication can be given in a defined period. Monitoring every 1 to 2 hours for patient response is sufficient.

 

DIF:    Cognitive Level: Applying              REF:   p. 176

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity

 

  1. Which drug is usually the best choice for patient-controlled analgesia (PCA) for a child in the immediate postoperative period?
a. Codeine sulfate (Codeine)
b. Morphine (Roxanol)
c. Methadone (Dolophine)
d. Meperidine (Demerol)

 

 

ANS:  B

The most commonly prescribed medications for PCA are morphine, hydromorphone, and fentanyl. Parenteral use of codeine is not recommended. Methadone in parenteral form is not used in a PCA but is given orally or intravenously for pain in the infant. Meperidine is not used for continuous and extended pain relief.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 176

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A child is in the intensive care unit after a motor vehicle collision. The child has numerous fractures and is in pain that is rated 9 or 10 on a 10-point scale. In planning care, the nurse recognizes that the indicated action is which?
a. Give only an opioid analgesic at this time.
b. Increase dosage of analgesic until the child is adequately sedated.
c. Plan a preventive schedule of pain medication around the clock.
d. Give the child a clock and explain when she or he can have pain medications.

 

 

ANS:  C

For severe postoperative pain, a preventive around the clock (ATC) schedule is necessary to prevent decreased plasma levels of medications. The opioid analgesic will help for the present, but it is not an effective strategy. Increasing the dosage requires an order. The nurse should give the drug on a regular schedule and evaluate the effectiveness. Using a clock is counterproductive because it focuses the child’s attention on how long he or she will need to wait for pain relief.

 

DIF:    Cognitive Level: Implementation    REF:   p. 176            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. The parents of a preterm infant in a neonatal intensive care unit are concerned about their infant experiencing pain from so many procedures. The nurse’s response should be based on which characteristic about preterm infants’ pain?
a. They may react to painful stimuli but are unable to remember the pain experience.
b. They perceive and react to pain in much the same manner as children and adults.
c. They do not have the cortical and subcortical centers that are needed for pain perception.
d. They lack neurochemical systems associated with pain transmission and modulation.

 

 

ANS:  B

Numerous research studies have indicated that preterm and newborn infants perceive and react to pain in the same manner as children and adults. Preterm infants can have significant reactions to painful stimuli. Pain can cause oxygen desaturation and global stress response. These physiologic effects must be avoided by use of appropriate analgesia. Painful stimuli cause a global stress response, including cardiorespiratory changes, palmar sweating, increased intracranial pressure, and hormonal and metabolic changes. Adequate analgesia and anesthesia are necessary to decrease the stress response.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 153

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity

 

  1. A preterm infant has just been admitted to the neonatal intensive care unit. The infant’s parents ask the nurse about anesthesia and analgesia when painful procedures are necessary. What should the nurse’s explanation be?
a. Nerve pathways of neonates are not sufficiently myelinated to transmit painful stimuli.
b. The risks accompanying anesthesia and analgesia are too great to justify any possible benefit of pain relief.
c. Neonates do not possess sufficiently integrated cortical function to interpret or recall pain experiences.
d. Pain pathways and neurochemical systems associated with pain transmission are intact and functional in neonates.

 

 

ANS:  D

Pain pathways and neurochemical systems associated with pain transmission are intact and functional in neonates. Painful stimuli cause a global stress response, including cardiorespiratory changes, palmar sweating, increased intracranial pressure, and hormonal and metabolic changes. Adequate analgesia and anesthesia are necessary to decrease the stress response. The pathways are sufficiently myelinated to transmit the painful stimuli and produce the pain response. Local and systemic pharmacologic agents are available to permit anesthesia and analgesia for neonates.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 185

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity

 

  1. A bone marrow aspiration and biopsy are needed on a school-age child. The most appropriate action to provide analgesia during the procedure is which?
a. Administer TAC (tetracaine, adrenalin, and cocaine) 15 minutes before the procedure.
b. Use a combination of fentanyl and midazolam for conscious sedation.
c. Apply EMLA (eutectic mixture of local anesthetics) 1 hour before the procedure.
d. Apply a transdermal fentanyl (Duragesic) “patch” immediately before the procedure.

 

 

ANS:  B

A bone marrow biopsy is a painful procedure. The combination of fentanyl and midazolam should be used to provide conscious sedation. TAC provides skin anesthesia about 15 minutes after it is applied to nonintact skin. The gel can be placed on a wound for suturing. It is not sufficient for a bone marrow biopsy. EMLA is an effective topical analgesic agent when applied to the skin 60 minutes before a procedure. It eliminates or reduces the pain from most procedures involving skin puncture. For this procedure, systemic analgesia is required. Transdermal fentanyl patches are useful for continuous pain control, not rapid pain control.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 185

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. What is a significant common side effect that occurs with opioid administration?
a. Euphoria
b. Diuresis
c. Constipation
d. Allergic reactions

 

 

ANS:  C

Constipation is one of the most common side effects of opioid administration. Preventive strategies should be implemented to minimize this problem. Sedation is a more common result than euphoria. Urinary retention, not diuresis, may occur with opiates. Rarely, some individuals may have pruritus.

 

DIF:    Cognitive Level: Remembering      REF:   p. 171            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is caring for a child receiving a continuous intravenous (IV) low-dose infusion of morphine for severe postoperative pain. The nurse observes a slower respiratory rate, and the child cannot be aroused. The most appropriate management of this child is for the nurse to do which first?
a. Administer naloxone (Narcan).
b. Discontinue the IV infusion.
c. Discontinue morphine until the child is fully awake.
d. Stimulate the child by calling his or her name, shaking gently, and asking the child to breathe deeply.

 

 

ANS:  A

The management of opioid-induced respiratory depression includes lowering the rate of infusion and stimulating the child. If the respiratory rate is depressed and the child cannot be aroused, then IV naloxone should be administered. The child will be in pain because of the reversal of the morphine. The morphine should be discontinued, but naloxone is indicated if the child is unresponsive.

 

DIF:    Cognitive Level: Applying              REF:   p. 180

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is teaching a staff development program about levels of sedation in the pediatric population. Which statement by one of the participants should indicate a correct understanding of the teaching?
a. “With minimal sedation, the patient’s respiratory efforts are affected, and cognitive function is not impaired.”
b. “With general anesthesia, the patient’s airway cannot be maintained, but cardiovascular function is maintained.”
c. “During deep sedation, the patient can be easily aroused by loud verbal commands and tactile stimulation.”
d. “During moderate sedation, the patient responds to verbal commands but may not respond to light tactile stimulation.”

 

 

ANS:  D

When discussing levels of sedation, the participants should understand that during moderate sedation, the patient responds to verbal commands but may not respond to light tactile stimulation, cognitive function is impaired, and respiratory function is adequate. In minimal sedation, the patient responds to verbal commands and may have impaired cognitive function; the respiratory and cardiovascular systems are unaffected. In deep sedation, the patient cannot be easily aroused except by painful stimuli; the airway and spontaneous ventilation may be impaired, but cardiovascular function is maintained. With general anesthesia, the patient loses consciousness and cannot be aroused with painful stimuli, the airway cannot be maintained, and ventilation is impaired; cardiovascular function may or may not be impaired.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 184

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is planning to administer a nonopioid for pain relief to a child. Which timing should the nurse plan so the nonopioid takes effect?
a. 15 minutes until maximum effect
b. 30 minutes until maximum effect
c. 1 hour until maximum effect
d. 1 1/2 hours until maximum effect

 

 

ANS:  C

Nonsteroidal antiinflammatory drugs (NSAIDs) can provide safe and effective pain relief when dosed at appropriate levels with adequate frequency. Most NSAIDs take about 1 hour for effect, so timing is crucial.

 

DIF:    Cognitive Level: Applying              REF:   p. 171            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is planning pain control for a child. Which is the advantage of administering pain medication by the intravenous (IV) bolus route?
a. Less expensive than oral medications
b. Produces a first-pass effect through the liver
c. Does not need to be administered frequently
d. Provides most rapid onset of effect, usually in about 5 minutes

 

 

ANS:  D

The advantage of pain medication by the IV bolus route is that it provides the most rapid onset of effect, usually in about 5 minutes. IV medications are more expensive than oral medications, and the IV route bypasses the first-pass effect through the liver. Pain control with IV bolus medication needs to be repeated hourly for continuous pain control.

 

DIF:    Cognitive Level: Applying              REF:   p. 176            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is teaching the parents of a child with recurrent headaches methods to modify behavior patterns that increase the risk of headache. Which statement by the parents indicates understanding the teaching?
a. “We will allow the child to miss school if a headache occurs.”
b. “We will respond matter-of-factly to requests for special attention.”
c. “We will be sure to give much attention to our child when a headache occurs.”
d. “We will be sure our child doesn’t have to perform at a band concert if a headache occurs.”

 

 

ANS:  B

To modify behavior patterns that increase the risk of headache or reinforce headache activity, the nurse instructs the parents to avoid giving excessive attention to their child’s headache and to respond matter-of-factly to pain behavior and requests for special attention. Parents learn to assess whether the child is avoiding school or social performance demands because of headache.

 

DIF:    Cognitive Level: Applying              REF:   p. 186

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity

 

  1. Which is a complication that can occur after abdominal surgery if pain is not managed?
a. Atelectasis
b. Hypoglycemia
c. Decrease in heart rate
d. Increase in cardiac output

 

 

ANS:  A

Pain associated with surgery in the abdominal region (e.g., appendectomy, cholecystectomy, splenectomy) may result in pulmonary complications. Pain leads to decreased muscle movement in the thorax and abdominal area and leads to decreased tidal volume, vital capacity, functional residual capacity, and alveolar ventilation. The patient is unable to cough and clear secretions, and the risk for complications such as pneumonia and atelectasis is high. Severe postoperative pain also results in sympathetic overactivity, which leads to increases in heart rate, peripheral resistance, blood pressure, and cardiac output. Hypoglycemia, decreases in heart rate, and increases in cardiac output are not complications of poor pain management.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 185

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. A burn patient is experiencing anxiety over dressing changes. Which prescription should the nurse expect to be ordered to control anxiety?
a. Lorazepam (Ativan)
b. Oxycodone (OxyContin)
c. Fentanyl (Sublimaze)
d. Morphine Sulfate (Morphine)

 

 

ANS:  A

A benzodiazepine such as lorazepam is prescribed as an antianxiety agent. Oxycodone, fentanyl, and morphine sulfate are opioid analgesics.

 

DIF:    Cognitive Level: Applying              REF:   p. 186            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. A cancer patient is experiencing neuropathic cancer pain. Which prescription should the nurse expect to be ordered to control anxiety?
a. Lorazepam (Ativan)
b. Gabapentin (Neurontin)
c. Hydromorphone (Dilaudid)
d. Morphine sulfate (MS Contin)

 

 

ANS:  B

Anticonvulsants (gabapentin, carbamazepine) have demonstrated effectiveness in neuropathic cancer pain. Ativan is an antianxiety agent, and Dilaudid and MS Contin are opioid analgesics.

 

DIF:    Cognitive Level: Applying              REF:   p. 189            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

MULTIPLE RESPONSE

 

  1. Which are components of the FLACC scale? (Select all that apply.)
a. Color
b. Capillary refill time
c. Leg position
d. Facial expression
e. Activity

 

 

ANS:  C, D, E

Facial expression, consolability, cry, activity, and leg position are components of the FLACC scale. Color is a component of the Apgar scoring system. Capillary refill time is a physiologic measure that is not a component of the FLACC scale.

 

DIF:    Cognitive Level: Understanding     REF:   p. 154

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is using the CRIES pain assessment tool on a preterm infant in the neonatal intensive care unit. Which are the components of this tool? (Select all that apply.)
a. Color
b. Moro reflex
c. Oxygen saturation
d. Posture of arms and legs
e. Sleeplessness
f. Facial expression

 

 

ANS:  C, E, F

Need for increased oxygen, crying, increased vital signs, expression, and sleeplessness are components of the CRIES pain assessment tool used with neonates. Color, Moro reflex, and posture of arms and legs are not components of the CRIES scale.

 

DIF:    Cognitive Level: Applying              REF:   p. 159

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. Which coanalgesics should the nurse expect to be prescribed for pruritus? (Select all that apply.)
a. Naloxone (Narcan)
b. Inapsine (Droperidol)
c. Hydroxyzine (Atarax)
d. Promethazine (Phenergan)
e. Diphenhydramine (Benadryl)

 

 

ANS:  A, C, E

The coanalgesics prescribed for pruritus include naloxone, hydroxyzine, and diphenhydramine. Inapsine and promethazine are administered as antiemetics.

 

DIF:    Cognitive Level: Applying              REF:   p. 174            TOP:   Nursing Process: Evaluation

MSC:  Client Needs: Physiological Integrity

 

  1. A child receiving chemotherapy is experiencing mucositis. Which prescriptions should the nurse plan to administer for initial treatment? (Select all that apply.)
a. Scope mouth rinse
b. Listerine antiseptic mouth rinse
c. Carafate suspension (Sucralfate)
d. Nystatin oral suspension (Nystatin)
e. Lidocaine viscous (Lidocaine hydrochloride solution)

 

 

ANS:  C, D, E

Initial treatment of stomatitis includes single agents (sucralfate suspension, nystatin, and viscous lidocaine). Scope and Listerine are plaque and gingivitis control mouth rinses that would have a drying effect and are not used with mucositis.

 

DIF:    Cognitive Level: Applying              REF:   p. 188            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

COMPLETION

 

  1. A health care provider prescribes promethazine (Phenergan), 9 mg IV every 6 to 8 hours as needed for pruritus. The medication label states: “Promethazine 25 mg/1 mL.” The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer using two decimal places.

________________

 

ANS:

0.36

 

Follow the formula for dosage calculation.

Desired

———– ´ Volume = mL per dose

Available

 

9 mg

———– ´ 1 mL = 0.36 mL

25 mg

 

DIF:    Cognitive Level: Applying              REF:   p. 174

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A health care provider prescribes diphenhydramine (Benadryl), 1 mg/kg PO every 4 to 6 hours as needed for pruritus. The child weighs 10 kg. The medication label states: “Diphenhydramine 12.5 mg/5 mL.” The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer in a whole number.

________________

 

ANS:

4

 

Follow the formula for dosage calculation.

Multiply 1 mg ´ 10 kg to get the dose = 10 mg

 

 

Desired

———– ´ Volume = mL per dose

Available

 

10 mg

———– ´ 5 mL = 4 mL

12.5 mg

 

DIF:    Cognitive Level: Applying              REF:   p. 174

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A health care provider prescribes hydroxyzine (Atarax), 0.6 mg/kg PO every 4 to 6 hours as needed for pruritus. The medication label states: “Hydroxyzine 10 mg/5 mL.” The child weighs 20 kg. The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer in a whole number.

________________

 

ANS:

6

 

Follow the formula for dosage calculation.

Multiply 0.6 mg ´ 20 kg to get the dose = 12 mg

 

Desired

———– ´ Volume = mL per dose

Available

 

12 mg

———– ´ 5 mL = 6 mL

10 mg

 

DIF:    Cognitive Level: Applying              REF:   p. 174

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A child receiving morphine sulfate (Morphine) is experiencing respiratory depression. A health care provider prescribes naloxone (Narcan), 0.5 mcg/kg IV in 2-minute increments until breathing improves. The medication label states: “Naloxone 400 mcg/1 mL.” The child weighs 40 kg. The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer using two decimal places.

________________

 

ANS:

0.05

 

Follow the formula for dosage calculation.

Multiply 0.5 mcg ´ 40 kg to get the dose = 20 mcg

 

Desired

———– ´ Volume = mL per dose

Available

 

20 mcg

———– ´ 1 mL = 0.05 mL

400 mcg

 

DIF:    Cognitive Level: Applying              REF:   p. 176

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A health care provider prescribes haloperidol (Haldol), 0.15 mg/kg IV every 4 to 6 hours as needed for confusion. The medication label states: “Haloperidol 2 mg/1 mL.” The child weighs 30 kg. The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer rounding to one decimal place.

________________

 

ANS:

2.3

 

Follow the formula for dosage calculation.

Multiply 0.15 mg ´ 30 kg to get the dose = 4.5 mg

 

Desired

———– ´ Volume = mL per dose

Available

 

4.5 mg

———– ´ 1 mL = 2.25 mL = rounded to one decimal space = 2.3 mL

2 mg

 

DIF:    Cognitive Level: Applying              REF:   p. 175

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A health care provider prescribes Kytril (granisetron), 10 mcg/kg IV every 4 to 6 hours as needed for nausea. The medication label states: “Kytril 100 mcg/1 mL.” The child weighs 15 kg. The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer to one decimal place.

_______________

 

ANS:

1.5

 

Follow the formula for dosage calculation.

Multiply 10 mcg ´ 15 kg to get the dose = 150 mcg

 

Desired

———– ´ Volume = mL per dose

Available

 

150 mcg

———– ´ 1 mL = 1.5 mL

100 mcg

 

DIF:    Cognitive Level: Applying              REF:   p. 174

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A health care provider prescribes OxyContin (oxycodone), 3 mg PO every 4 to 6 hours as needed for pain. The medication label states: “OxyContin 5 mg/1 mL.” The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer using one decimal place.

________________

 

ANS:

0.6

 

Follow the formula for dosage calculation.

Desired

———– ´ Volume = mL per dose

Available

 

3 mg

———– ´ 1 mL = 0.6 mL

5 mg

 

DIF:    Cognitive Level: Applying              REF:   p. 172

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A health care provider prescribes acetaminophen (Tylenol) gtt, 10 mg/kg/dose PO every 4 to 6 hours as needed for pain. The infant weighs 8 kg. The medication label states: “Acetaminophen 80 mg/0.8 mL.” The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer to one decimal place.

________________

 

ANS:

0.8

 

Follow the formula for dosage calculation.

Multiply 10 mg ´ 8 kg to get the dose = 80 mg

 

Desired

———– ´ Volume = mL per dose

Available

 

80 mg

———– ´ 0.8 mL = 0.8 mL

80 mg

 

DIF:    Cognitive Level: Applying              REF:   p. 171

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A health care provider prescribes naproxen (Naprosyn), 7 mg/kg PO every 12 hours for pain. The child weighs 25 kg. The medication label states: “Naproxen 125 mg/5 mL.” The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer in a whole number.

________________

 

ANS:

7

 

Follow the formula for dosage calculation.

Multiply 7 mg ´ 25 kg to get the dose = 175 mg

 

Desired

———– ´ Volume = mL per dose

Available

 

175 mg

———– ´ 5 mL = 7 mL

125 mg

 

DIF:    Cognitive Level: Applying              REF:   p. 171

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A health care provider prescribes choline magnesium trisalicylate (Trilisate), 15 mg/kg PO every 8 to 12 hours as needed for pain. The child weighs 10 kg. The medication label states: “Choline magnesium trisalicylate 500 mg/5 mL.” The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer to one decimal place.

________________

 

ANS:

1.5

 

Follow the formula for dosage calculation.

Multiply 15 mg ´ 10 kg to get the dose = 150 mg

 

Desired

———– ´ Volume = mL per dose

Available

 

150 mg

———– ´ 5 mL = 1.5 mL

500 mg

 

DIF:    Cognitive Level: Applying              REF:   p. 171

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A health care provider prescribes ibuprofen (Motrin), 5 mg/kg PO every 6 to 8 hours as needed for pain. The child weighs 8 kg. The medication label states: “Ibuprofen 100 mg/5 mL.” The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer in a whole number.

________________

 

ANS:

2

 

Follow the formula for dosage calculation.

Multiply 5 mg ´ 8 kg to get the dose = 40 mg

 

Desired

———– ´ Volume = mL per dose

Available

 

40 mg

———– ´ 5 mL = 2 mL

100 mg

 

DIF:    Cognitive Level: Applying              REF:   p. 171

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

MATCHING

 

Complementary and alternative medicine therapies are grouped into five classes. Match the complementary or alternative therapy to its classification.

a. Vitamins
b. Massage
c. Reiki
d. Hypnosis
e. Homeopathy

 

 

  1. Manipulative treatment

 

  1. Energy based

 

  1. Alternative medical system

 

  1. Mind–body technique

 

  1. Biologically based

 

  1. ANS:  B                    DIF:    Cognitive Level: Understanding     REF:   p. 170

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. ANS:  C                    DIF:    Cognitive Level: Understanding     REF:   p. 170

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. ANS:  E                    DIF:    Cognitive Level: Understanding     REF:   p. 170

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. ANS:  D                    DIF:    Cognitive Level: Understanding     REF:   p. 170

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. ANS:  A                    DIF:    Cognitive Level: Understanding     REF:   p. 170

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

Chapter 07: Health Promotion of the Newborn and Family

 

MULTIPLE CHOICE

 

  1. What is a function of brown adipose tissue (BAT) in newborns?
a. Generates heat for distribution to other parts of body
b. Provides ready source of calories in the newborn period
c. Protects newborns from injury during the birth process
d. Insulates the body against lowered environmental temperature

 

 

ANS:  A

Brown fat is a unique source of heat for newborns. It has a larger content of mitochondrial cytochromes and a greater capacity for heat production through intensified metabolic activity than does ordinary adipose tissue. Heat generated in brown fat is distributed to other parts of the body by the blood. It is effective only in heat production. Brown fat is located in superficial areas such as between the scapulae, around the neck, in the axillae, and behind the sternum. These areas should not protect the newborn from injury during the birth process. The newborn has a thin layer of subcutaneous fat, which does not provide for conservation of heat.

 

DIF:    Cognitive Level: Understanding     REF:   p. 244

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which characteristic is representative of a full-term newborn’s gastrointestinal tract?
a. Transit time is diminished.
b. Peristaltic waves are relatively slow.
c. Pancreatic amylase is overproduced.
d. Stomach capacity is very limited.

 

 

ANS:  D

Newborns require frequent small feedings because their stomach capacity is very limited. A newborn’s colon has a relatively small volume and resulting increased bowel movements. Peristaltic waves are rapid. A deficiency of pancreatic lipase limits the absorption of fats.

 

DIF:    Cognitive Level: Understanding     REF:   p. 245

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which term is used to describe a newborn’s first stool?
a. Milia
b. Milk stool
c. Meconium
d. Transitional

 

 

ANS:  C

Meconium is composed of amniotic fluid and its constituents, intestinal secretions, shed mucosal cells, and possibly blood. It is a newborn’s first stool. Milia involves distended sweat glands that appear as minute vesicles, primarily on the face. Milk stool usually occurs by the fourth day. The appearance varies depending on whether the newborn is breast or formula fed. Transitional stools usually appear by the third day after the beginning of feeding. They are usually greenish brown to yellowish brown, thin, and less sticky than meconium.

 

DIF:    Cognitive Level: Understanding     REF:   p. 245

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. In term newborns, the first meconium stool should occur no later than within how many hours after birth?
a. 6
b. 8
c. 12
d. 24

 

 

ANS:  D

The first meconium stool should occur within the first 24 hours. It may be delayed up to 7 days in very low–birth-weight newborns.

 

DIF:    Cognitive Level: Understanding     REF:   p. 245

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which is true regarding an infant’s kidney function?
a. Conservation of fluid and electrolytes occurs.
b. Urine has color and odor similar to the urine of adults.
c. The ability to concentrate urine is less than that of adults.
d. Normally, urination does not occur until 24 hours after delivery.

 

 

ANS:  C

At birth, all structural components are present in the renal system, but there is a functional deficiency in the kidney’s ability to concentrate urine and to cope with conditions of fluid and electrolyte stress such as dehydration or a concentrated solute load. Infants’ urine is colorless and odorless. The first voiding usually occurs within 24 hours of delivery. Newborns void when the bladder is stretched to 15 ml, resulting in about 20 voidings per day.

 

DIF:    Cognitive Level: Understanding     REF:   p. 245

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The Apgar score of an infant 5 minutes after birth is 8. Which is the nurse’s best interpretation of this?
a. Resuscitation is likely to be needed.
b. Adjustment to extrauterine life is adequate.
c. Additional scoring in 5 more minutes is needed.
d. Maternal sedation or analgesia contributed to the low score.

 

 

ANS:  B

The Apgar reflects an infant’s status in five areas: heart rate, respiratory effort, muscle tone, reflex irritability, and color. A score of 8 to 10 indicates an absence of difficulty adjusting to extrauterine life. Scores of 0 to 3 indicate severe distress, and scores of 4 to 7 indicate moderate difficulty. All infants are rescored at 5 minutes of life, and a score of 8 is not indicative of distress; the newborn does not have a low score. The Apgar score is not used to determine the infant’s need for resuscitation at birth.

 

DIF:    Cognitive Level: Understanding     REF:   p. 247

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. Which statement best represents the first stage or the first period of reactivity in the infant?
a. Begins when the newborn awakes from a deep sleep
b. Is an excellent time to acquaint the parents with the newborn
c. Ends when the amounts of respiratory mucus have decreased
d. Provides time for the mother to recover from the childbirth process

 

 

ANS:  B

During the first period of reactivity, the infant is alert, cries vigorously, may suck his or her fist greedily, and appears interested in the environment. The infant’s eyes are usually wide open, suggesting that this is an excellent opportunity for mother, father, and infant to see each other. The second period of reactivity begins when the infant awakes from a deep sleep and ends when the amounts of respiratory mucus have decreased. The mother should sleep and recover during the second stage, when the infant is sleeping.

 

DIF:    Cognitive Level: Applying              REF:   p. 247

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which statement reflects accurate information about patterns of sleep and wakefulness in the newborn?
a. States of sleep are independent of environmental stimuli.
b. The quiet alert stage is the best stage for newborn stimulation.
c. Cycles of sleep states are uniform in newborns of the same age.
d. Muscle twitches and irregular breathing are common during deep sleep.

 

 

ANS:  B

During the quiet alert stage, the newborn’s eyes are wide open and bright. The newborn responds to the environment by active body movement and staring at close-range objects. Newborns’ ability to control their own cycles depend on their neurobehavioral development. Each newborn has an individual cycle. Muscle twitches and irregular breathing are common during light sleep.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 249

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse observes that a new mother avoids making eye contact with her infant. What should the nurse do?
a. Ask the mother why she won’t look at the infant.
b. Examine the infant’s eyes for the ability to focus.
c. Assess the mother for other attachment behaviors.
d. Recognize this as a common reaction in new mothers.

 

 

ANS:  C

Attachment behaviors are thought to indicate the formation of emotional bonds between the newborn and mother. A mother’s failure to make eye contact with her infant may indicate difficulties with the formation of emotional bonds. The nurse should perform a more thorough assessment. Asking the mother why she will not look at the infant is a confrontational response that might put the mother in a defensive position. Infants do not have binocularity and cannot focus. Avoiding eye contact is an uncommon reaction in new mothers.

 

DIF:    Cognitive Level: Applying              REF:   p. 249

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which should the nurse use when assessing the physical maturity of a newborn?
a. Length
b. Apgar score
c. Posture at rest
d. Chest circumference

 

 

ANS:  C

With the newborn quiet and in a supine position, the degree of flexion in the arms and legs can be used for determination of gestational age. Length and chest circumference reflect the newborn’s size and weight, which vary according to race and gender. Birth weight alone is a poor indicator of gestational age and fetal maturity. The Apgar score is an indication of the newborn’s adjustment to extrauterine life.

 

DIF:    Cognitive Level: Applying              REF:   p. 251

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What is the grayish white, cheeselike substance that covers the newborn’s skin?
a. Milia
b. Meconium
c. Amniotic fluid
d. Vernix caseosa

 

 

ANS:  D

The vernix caseosa is the grayish white, cheeselike substance that covers a newborn’s skin.

 

DIF:    Cognitive Level: Remembering      REF:   p. 260

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What is most descriptive of the shape of the anterior fontanel in a newborn?
a. Circle
b. Square
c. Triangle
d. Diamond

 

 

ANS:  D

The anterior fontanel is diamond shaped and measures from barely palpable to 4 to 5 cm. The shape of the posterior fontanel is a triangle. Neither of the fontanels is a circle or a square.

 

DIF:    Cognitive Level: Remembering      REF:   p. 261

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which term describes irregular areas of deep blue pigmentation seen predominantly in infants of African, Asian, Native American, or Hispanic descent?
a. Acrocyanosis
b. Mongolian spots
c. Erythema toxicum
d. Harlequin color change

 

 

ANS:  B

Mongolian spots are irregular areas of deep blue pigmentation, which are common variations found in newborns of African, Asian, Native American, or Hispanic descent. Acrocyanosis is cyanosis of the hands and feet; this is a usual finding in infants. Erythema toxicum is a pink papular rash with vesicles that may appear in 24 to 48 hours and resolve after several days. Harlequin color changes are clearly outlined areas of color change. As the infant lies on a side, the lower half of the body becomes pink, and the upper half is pale.

 

DIF:    Cognitive Level: Understanding     REF:   p. 254

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse should expect the apical heart rate of a stabilized newborn to be in which range?
a. 60 to 80 beats/min
b. 80 to 100 beats/min
c. 120 to 140 beats/min
d. 160 to 180 beats/min

 

 

ANS:  C

The pulse rate of the newborn varies with periods of reactivity. Usually the pulse rate is between 120 and 140 beats/min. Sixty to 100 beats/min is too slow for a newborn, and 160 to 180 beats/min is too fast for a newborn.

 

DIF:    Cognitive Level: Understanding     REF:   p. 259

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which finding in the newborn is considered abnormal?
a. Nystagmus
b. Profuse drooling
c. Dark green or black stools
d. Slight vaginal reddish discharge

 

 

ANS:  B

Profuse drooling and salivation are potential signs of a major abnormality. Newborns with esophageal atresia cannot swallow their oral secretions, resulting in excessive drooling. Nystagmus is an involuntary movement of the eyes. This is a common variation in newborns. Meconium, the first stool of newborns, is dark green or black. A pseudomenstruation may be present in normal newborns. This is a blood-tinged or mucoid vaginal discharge.

 

DIF:    Cognitive Level: Understanding     REF:   p. 256

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. When doing the first assessment of a male newborn, the nurse notes that the scrotum is large, edematous, and pendulous. What should this be interpreted as?
a. A hydrocele
b. An inguinal hernia
c. A normal finding
d. An absence of testes

 

 

ANS:  C

A large, edematous, and pendulous scrotum in a term newborn, especially in those born in a breech position, is a normal finding. A hydrocele is fluid in the scrotum, usually unilateral, which usually resolves within a few months. An inguinal hernia may or may not be present at birth. It is more easily detected when the child is crying. The presence or absence of testes should be determined on palpation of the scrotum and inguinal canal. Absence of testes may be an indication of ambiguous genitalia.

 

DIF:    Cognitive Level: Understanding     REF:   p. 257

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Why are rectal temperatures not recommended in newborns?
a. They are inaccurate.
b. They do not reflect core body temperature.
c. They can cause perforation of rectal mucosa.
d. They take too long to obtain an accurate reading.

 

 

ANS:  C

Rectal temperatures are avoided in newborns. If done incorrectly, the insertion of a thermometer into the rectum can cause perforation of the mucosa. The time it takes to determine body temperature is related to the equipment used, not only the route.

 

DIF:    Cognitive Level: Understanding     REF:   p. 259

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. Which is the name of the suture separating the parietal bones at the top of a newborn’s head?
a. Frontal
b. Sagittal
c. Coronal
d. Occipital

 

 

ANS:  B

The sagittal suture separates the parietal bones at the top of the newborn’s head. The frontal suture separates the frontal bones. The coronal suture is said to “crown the head.” The lambdoid suture is at the margin of the parietal and occipital.

 

DIF:    Cognitive Level: Understanding     REF:   p. 261

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse observes flaring of nares in a newborn. What should this be interpreted as?
a. Nasal occlusion
b. Sign of respiratory distress
c. Snuffles of congenital syphilis
d. Appropriate newborn breathing

 

 

ANS:  B

Nasal flaring is an indication of respiratory distress. A nasal occlusion should prevent the child from breathing through the nose. Because newborns are obligatory nose breathers, this should require immediate referral. Snuffles are indicated by a thick, bloody nasal discharge without sneezing. Sneezing and thin, white mucus drainage are common in newborns and are not related to nasal flaring.

 

DIF:    Cognitive Level: Understanding     REF:   p. 255

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is assessing the reflexes of a newborn. Stroking the outer sole of the foot assesses which reflex?
a. Grasp
b. Perez
c. Babinski
d. Dance or step

 

 

ANS:  C

This is a description of the Babinski reflex. Stroking the outer sole of the foot upward from the heel across the ball of the foot causes the big toes to dorsiflex and the other toes to hyperextend. This reflex persists until approximately age 1 year or when the newborn begins to walk. The grasp reflex is elicited by touching the palms or soles at the base of the digits. The digits will flex or grasp. The Perez reflex involves stroking the newborn’s back when prone; the child flexes the extremities, elevating the head and pelvis. This disappears at ages 4 to 6 months. When the newborn is held so that the sole of the foot touches a hard surface, there is a reciprocal flexion and extension of the leg, simulating walking. This reflex disappears by ages 3 to 4 weeks.

 

DIF:    Cognitive Level: Understanding     REF:   p. 266

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which is most important in the immediate care of the newborn?
a. Maintain a patent airway.
b. Administer prophylactic eye care.
c. Maintain a stable body temperature.
d. Establish identification of the mother and baby.

 

 

ANS:  A

Maintaining a patent airway is the primary objective in the care of the newborn. First, the pharynx is cleared with a bulb syringe followed by the nasal passages. Administering prophylactic eye care and establishing identification of the mother and baby are important functions, but physiologic stability is the first priority in the immediate care of the newborn. Conserving the newborn’s body heat and maintaining a stable body temperature are important, but a patent airway must be established first.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 267            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. What should nursing interventions to maintain a patent airway in a newborn include?
a. Positioning the newborn supine after feedings.
b. Wrapping the newborn as snugly as possible.
c. Placing the newborn to sleep in the prone (on abdomen) position.
d. Using a bulb syringe to suction as needed, suctioning the nose first and then the pharynx.

 

 

ANS:  A

Positioning the newborn supine after feedings is recommended by the American Academy of Pediatrics to prevent sudden newborn death syndrome. The child can be wrapped snugly but should be placed on the side or back. Placing a newborn to sleep in the prone (on abdomen) position is not advised because of the possible link between sleeping in the prone position and sudden newborn death syndrome. A bulb syringe should be kept by the bedside if necessary, but the pharynx should be suctioned before the nose.

 

DIF:    Cognitive Level: Applying              REF:   p. 267

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. The nurse quickly dries the newborn after delivery. This is to conserve the newborn’s body heat by preventing heat loss through which method?
a. Radiation
b. Conduction
c. Convection
d. Evaporation

 

 

ANS:  D

Evaporation is the loss of heat through moisture. The newborn should be quickly dried of the amniotic fluid. Radiation is the loss of heat to a cooler solid object. The cold air from either the window or the air conditioner will cool the walls of the incubator and subsequently the body of the newborn. Conduction involves the loss of heat from the body because of direct contact of the skin with a cooler object. Convection is similar to conduction but is the loss of heat aided by air currents.

 

DIF:    Cognitive Level: Applying              REF:   p. 267

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. An infant is being discharged at 48 hours of age. The parents ask how the infant should be bathed this first week home. Which is the best recommendation by the nurse?
a. Bathe the infant daily with mild soap.
b. Bathe the infant daily with an alkaline soap.
c. Bathe the infant two or three times this week with mild soap.
d. Bathe the infant two or three times this week with plain water.

 

 

ANS:  D

A newborn infant’s skin has a pH of approximately 5. This acidic pH has a bacteriostatic effect. The parents should be taught to use only plain warm water for the bath and to bathe the infant no more than two or three times the first 2 weeks. Soaps are alkaline. They will alter the acid mantle of the infant’s skin, providing a medium for bacterial growth.

 

DIF:    Cognitive Level: Applying              REF:   p. 271

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The stump of the umbilical cord usually drops off in how many days?
a. 3 to 6
b. 10 to 14
c. 16 to 21
d. 24 to 28

 

 

ANS:  B

The average umbilical cord separates in 10 to 14 days. Three to 6 days is too soon, and 16 to 28 days is too late.

 

DIF:    Cognitive Level: Understanding     REF:   p. 271

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The parents of an infant plan to have him circumcised. They ask the nurse about pain associated with this procedure. The nurse’s response should be based on which?
a. That infants experience pain with circumcision
b. That infants are too young for anesthesia or analgesia
c. That infants do not experience pain with circumcision
d. That infants quickly forget about the pain of circumcision

 

 

ANS:  A

Circumcision is a surgical procedure. The American Academy of Pediatrics has recommended that procedural analgesia be provided when circumcision is performed. The pain infants experience with surgical procedures can be alleviated with analgesia. Infants who undergo circumcision without anesthetic agents react more intensely to immunization injections at 4 to 6 months of age compared with infants who had an anesthetic.

 

DIF:    Cognitive Level: Applying              REF:   p. 272

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is teaching a class on breastfeeding to expectant parents. Which is a contraindication for breastfeeding?
a. Mastitis
b. Twin births
c. Inverted nipples
d. Maternal cancer therapy

 

 

ANS:  D

Mothers receiving chemotherapy with antimetabolites and certain antineoplastic drugs should not breastfeed. The drugs are passed to the newborn through the breast milk. Mastitis, twin births, and inverted nipples are not contraindications.

 

DIF:    Cognitive Level: Applying              REF:   p. 277

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Successful breastfeeding is most dependent on which?
a. Birth weight of newborn
b. Size of mother’s breasts
c. Mother’s desire to breastfeed
d. Family’s socioeconomic level

 

 

ANS:  C

The factors that contribute to successful breastfeeding are the mother’s desire to breastfeed, satisfaction with breastfeeding, and available support systems. Very low–birth-weight infants may be unable to breastfeed. The mother can express milk, and it can be used for the infant. The size of mother’s breasts does not affect the success of breastfeeding. The family’s socioeconomic level may affect the mother’s need to return to work and available support systems, but with support, the mother can be successful.

 

DIF:    Cognitive Level: Applying              REF:   p. 279            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A mother who breastfeeds her 6-week-old infant every 4 hours tells the nurse that he seems “hungry all the time.” The nurse should recommend which?
a. Newborn cereal
b. Supplemental formula
c. More frequent feedings
d. No change in feedings

 

 

ANS:  C

Infants who are breastfed tend to be hungry every 2 to 3 hours. They should be fed frequently. Six weeks is too early to introduce newborn cereal. Supplemental formula is not indicated. Giving additional formula or water to a breastfed infant may satiate the infant and create problems with breastfeeding. The infant requires additional feedings. Four hours is too long between feedings for a breastfed infant.

 

DIF:    Cognitive Level: Applying              REF:   p. 279

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What should a nursing intervention to promote parent–infant attachment include?
a. Encouraging parents to hold the infant frequently unless the infant is fussy
b. Explaining individual differences among infants to the parents
c. Delaying parent–infant interactions until the second period of reactivity
d. Alleviating stress for parents by decreasing their participation in the infant’s care

 

 

ANS:  B

Nurses can positively influence the attachment of parent and infant by recognizing and explaining individual differences to the parents. The nurse should emphasize the normalcy of these variations and demonstrate the uniqueness of each infant. The parents should be encouraged to hold the infant when he or she is fussy and learn how best to soothe their infant. The nurse should facilitate parent–infant interaction during the first period of reactivity. Decreasing the parents’ participation in care interferes with parent–infant attachment.

 

DIF:    Cognitive Level: Applying              REF:   p. 283

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A new mother wants to be discharged with her infant as soon as possible. Before discharge, what should the nurse be certain of?
a. The infant has voided at least once.
b. The infant does not spit up after feeding.
c. Jaundice, if present, appeared before 24 hours.
d. A follow-up appointment with the practitioner is made within 48 hours.

 

 

ANS:  D

The American Academy of Pediatrics recommends that newborns discharged early receive follow-up care within 48 hours in either a primary practitioner’s office or the home. The child should void every 4 to 6 hours. Spitting up small amounts after feeding is normal in newborns; it should not delay discharge. Jaundice within the first 24 hours of life must be evaluated.

 

DIF:    Cognitive Level: Applying              REF:   p. 287            TOP:   Nursing Process: Evaluation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is teaching new parents about the benefits of breastfeeding their infant. Which statement by the parent should indicate a correct understanding of the teaching?
a. “I should breastfeed my baby so that she will grow at a faster rate than a bottle-fed newborn.”
b. “One of the advantages of breastfeeding is that the baby will have fewer stools per day.”
c. “I should breastfeed my baby because breastfed babies adapt more easily to a regular schedule of feedings.”
d. “Some of the advantages of breastfeeding are that breast milk is economical and readily available for my baby.”

 

 

ANS:  D

Some advantages of breastfeeding a newborn are that breast milk is more economical, is readily available, and is sanitary. Breastfed newborns usually grow at a satisfactory, slower rate than bottle-fed newborns, which research indicates aids in decreased obesity in children. Breastfed babies have an increased number of stools throughout a 24-hour period, and neither breastfed nor bottle-fed newborns should be placed on a regular schedule; they should be fed on demand.

 

DIF:    Cognitive Level: Applying              REF:   p. 275

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is caring for a patient who has chosen to breastfeed her infant. Which statement should the nurse include when teaching the mother about breastfeeding problems that may occur?
a. “If you experience painful nipples, cleanse your nipples with soap two times per day and keep your nipples covered as much as possible.”
b. “If you experience plugged ducts, continue to breastfeed every 2 to 3 hours and alternate feeding positions.”
c. “If mastitis occurs, discontinue breastfeeding while taking prescribed antibiotics and apply warm compresses.”
d. “If engorgement occurs, use cold compresses before a feeding and wear a well-fitting bra at night.”

 

 

ANS:  B

If a woman experiences plugged ducts, the best interventions are to continue breastfeeding every 2 to 3 hours and alternate feeding positions while pointing the infant’s chin toward the obstructed area. Other interventions include massaging breasts and applying warm compresses before feeding or pumping. If painful nipples occur, the woman should avoid soaps, oils, and lotions and air the nipples as much as possible. If mastitis occurs, the woman should continue breastfeeding to keep the breast well drained. If engorgement occurs, the woman should use a warm compress before feedings and wear a well-fitting bra 24 hours a day.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 281            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

MULTIPLE RESPONSE

 

  1. The nurse is completing a physical and gestational age assessment on an infant who is 12 hours old. Which components are included in the gestational age assessment? (Select all that apply.)
a. Arm recoil
b. Popliteal angle
c. Motor performance
d. Primitive reflexes
e. Square window
f. Scarf sign

 

 

ANS:  A, B, E, F

The components of the typical gestational age assessment include posture, square window, arm recoil, popliteal angle, scarf sign, and heel to ear. Motor performance and reflexes are parts of the behaviors in the Brazelton Neonatal Behavioral Assessment Scale.

 

DIF:    Cognitive Level: Applying              REF:   p. 250

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is teaching parents about the visual ability of their newborn. Which should the nurse include in the teaching session? (Select all that apply.)
a. Visual acuity is between 20/100 and 20/400.
b. Tear glands do not begin to function until 8 to 12 weeks of age.
c. Infants can momentarily fixate on a bright object that is within 8 inches.
d. The infant demonstrates visual preferences of black-and-white contrasting patterns.
e. The infant prefers bright colors (red, orange, blue) over medium colors (yellow, green, pink).

 

 

ANS:  A, C, D

Visual acuity is reported to be between 20/100 and 20/400, depending on the vision measurement techniques. The infant has the ability to momentarily fixate on a bright or moving object that is within 20 cm (8 inches) and in the midline of the visual field. The infant demonstrates visual preferences of black-and-white contrasting patterns. The visual preference is for medium colors (yellow, green, pink) over dim or bright colors (red, orange, blue). Tear glands begin to function until 2 to 4 weeks of age.

 

DIF:    Cognitive Level: Applying              REF:   p. 246

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which assessments are included in the Apgar scoring system? (Select all that apply.)
a. Heart rate
b. Muscle tone
c. Blood pressure
d. Blood glucose
e. Reflex irritability

 

 

ANS:  A, B, E

The Apgar score is based on observation of heart rate, respiratory effort, muscle tone, reflex irritability, and color. Blood pressure and blood glucose are not part of the Apgar scoring system.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 247

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is completing a respiratory assessment on a newborn. What are normal findings of the assessment the nurse should document? (Select all that apply.)
a. Periodic breathing
b. Respiratory rate of 40 breaths/min
c. Wheezes on auscultation
d. Apnea lasting 25 seconds
e. Slight intercostal retractions

 

 

ANS:  A, B, E

Periodic breathing is common in full-term newborns and consists of rapid, nonlabored respirations followed by pauses of less than 20 seconds. The newborn’s respiratory rate is between 30 and 60 breaths/min. The ribs are flexible, and slight intercostal retractions are normal on inspiration. Periods of apnea lasting more than 20 seconds are abnormal, and wheezes should be reported.

 

DIF:    Cognitive Level: Applying              REF:   p. 263

TOP:   Integrated Process: Communication and Documentation

MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is instructing a new mother on safety measures for newborn abduction. Which should the nurse include in the instructions? (Select all that apply.)
a. Publish the birth announcement in your local newspaper.
b. Don’t relinquish the newborn to anyone without identification.
c. Keep your door open if the newborn is in the room while you shower.
d. Use a password system with the staff when the newborn is taken from the room.
e. When you use the restroom, ring for a nurse to stay in the room with your newborn.

 

 

ANS:  B, D, E

Safety measures to be taught to new mothers should include (1) not leaving the newborn alone in the crib while taking a shower or using the bathroom; rather, they should ask to have the newborn observed by a health care worker if a family member is not present in the room; (2) not relinquishing the newborn to anyone without identification; and (3) using a password system with the staff when the newborn is taken from the room as a routine security measure. The newborn should not be left alone while the mother is showering, even if the door is left open. It is recommended to not publish the birth announcement in the newspaper.

 

DIF:    Cognitive Level: Applying              REF:   p. 268

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. The nurse is conducting discharge teaching to parents regarding care of the umbilical cord. Which should the nurse include in the instructions? (Select all that apply.)
a. Cover the umbilical cord with the diaper.
b. The cord will fall off in 5 to 15 days.
c. Clean around the umbilical cord stump with water.
d. Watch for redness and drainage around the umbilical cord stump.
e. A tub bath can be done every other day.

 

 

ANS:  B, C, D

The umbilical cord is cleansed initially with sterile water or a neutral pH cleanser and then subsequently with water. The stump deteriorates through the process of dry gangrene, with an average separation time of 5 to 15 days. The umbilical cord area should be watched for redness or drainage, which could indicate infection. The diaper is placed below the cord to avoid irritation and wetness on the site, and tub bathing is not allowed until the umbilical cord falls off.

 

DIF:    Cognitive Level: Applying              REF:   p. 272

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

 

COMPLETION

 

  1. A health care provider prescribes vitamin K intramuscular 1 mg one time within 1 hour of birth. The medication label states: “Vitamin K 2 mg/1 ml.” The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer to one decimal place.

________________

 

ANS:

0.5

 

Follow the formula for dosage calculation.

Desired

———– ´ Volume = ml per dose

Available

 

1 mg

———– ´ 1 ml = 0.5 ml

2 mg

 

DIF:    Cognitive Level: Applying              REF:   p. 269

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

Chapter 09: The High-Risk Newborn and Family

 

MULTIPLE CHOICE

 

  1. Which refers to an infant whose rate of intrauterine growth has slowed and whose birth weight falls below the 10th percentile on intrauterine growth charts?
a. Postterm
b. Postmature
c. Low birth weight
d. Small for gestational age

 

 

ANS:  D

A small-for-gestational-age, or small-for-date, infant is one whose rate of intrauterine growth has slowed and whose birth weight falls below the 10th percentile on intrauterine growth curves. A postterm, or postmature, infant is any child born after 42 weeks of gestation, regardless of birth weight. A low-birth-weight infant is a child whose birth weight is less than 2500 g, regardless of gestational age.

 

DIF:    Cognitive Level: Understanding     REF:   p. 338

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A woman in premature labor delivers an extremely low–birth-weight (ELBW) infant. Transport to a neonatal intensive care unit is indicated. The nurse explains that which level of service is needed?
a. Level I
b. Level IA
c. Level II
d. Level IIIB

 

 

ANS:  D

A level IIIB neonatal unit has the capability of providing care for ELBW infants, including high-frequency ventilation and on-site access to medical subspecialties and pediatric surgery. A level I facility manages normal maternal and newborn care. Infants at less than 35 weeks of gestation are stabilized and transported to a facility that can provide appropriate care. A level IA facility does not exist. Level II facilities provide care for infants born at 32 weeks of gestation and weighing more than 1500 g. If the infant is ill, the health problems are expected to resolve rapidly and are not anticipated to require specialty care.

 

DIF:    Cognitive Level: Applying              REF:   p. 339

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity

 

  1. What is an essential component in caring for the very low– or extremely low–birth-weight infant?
a. Holding the infant to help develop trust
b. Using electronic monitoring devices exclusively
c. Coordinating care to reduce environmental stress
d. Incorporating infant stimulation elements during assessment

 

 

ANS:  C

One of the principles of care for high-risk neonates is close observation and assessment with minimum handling. The nurse checks the apical rate against the monitor readings on a regular basis. The infant’s care is then clustered, and the infant is disturbed as little as possible. Holding an infant to help develop trust is not part of the assessment. In some areas, parents use “skin-to-skin” care with their infants. Although electronic monitoring devices are used, the nurse must validate the readings with the infant’s data. For an ill neonate, excessive stimulation creates stress.

 

DIF:    Cognitive Level: Understanding     REF:   p. 339

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. What explains why a neutral thermal environment is essential for a high-risk neonate?
a. The neonate produces heat by increasing activity and shivering.
b. Metabolism slows dramatically in the neonate experiencing cold stress.
c. It permits the neonate to maintain a normal core temperature with minimum oxygen consumption.
d. It permits the neonate to maintain a normal core temperature with increased caloric consumption.

 

 

ANS:  C

A high-risk neonate is at greater risk for cold stress than a term infant because of the smaller muscle mass and fewer deposits of brown fat for producing heat, lack of insulating subcutaneous fat, and poor reflex control of skin capillaries. By definition, a neutral thermal environment is one that permits the infant to maintain a normal core temperature with minimum oxygen consumption and caloric expenditure. Smaller muscle mass and poor reflex control of skin capillaries decrease the ability of a high-risk neonate to compensate for an environment that is not thermoneutral. Metabolism increases in an infant experiencing cold stress, creating a compensatory increase in oxygen and caloric consumption. Increased caloric consumption is to be avoided. Neonates need available calories for growth.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 342            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. When caring for a neonate in a radiant warmer, what should the nurse be alert to?
a. Exposure to prolonged cold stress
b. Need for Plexiglas shields to protect the infant
c. Transepidermal water loss leading to dehydration
d. Increased risk of infection from the open environment

 

 

ANS:  C

Radiant warmers result in greater evaporative fluid loss than normal, thus predisposing the infant to dehydration. Plastic wrap can help reduce this loss. Daily fluid requirements are increased to compensate. The radiant warmer protects the infant from cold stress. Plexiglas shields are not used in radiant warmers because they block the radiant heat waves. With clean and aseptic technique, there is not a greater risk of infection.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 343            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is caring for a high-risk neonate who has an umbilical catheter and is in a radiant warmer. The nurse notes blanching of the feet. Which is the most appropriate nursing action?
a. Place socks on the infant’s feet.
b. Elevate the infant’s feet 15 degrees.
c. Wrap the infant’s feet loosely in a prewarmed blanket.
d. Report the findings immediately to the practitioner.

 

 

ANS:  D

Blanching of the feet in a neonate with an umbilical catheter is an indication of vasospasm. Vasoconstriction of the peripheral vessels, triggered by the vasospasm, can seriously impair circulation. It is an emergency situation and must be reported immediately.

 

DIF:    Cognitive Level: Applying              REF:   p. 344

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. Which statement is true concerning the nutritional needs of preterm infants?
a. The secretion of lactase is low.
b. Carbohydrates and fats are better tolerated than protein.
c. The demand for nutrients is less than in full-term infants.
d. Breast milk lacks the proper concentration of nutrients.

 

 

ANS:  A

The enzyme lactase is not readily available in an infant’s body until after 34 weeks of gestation. Formulas containing lactose are not well tolerated. Carbohydrates and fats are less well tolerated than protein. Preterm infants require significantly higher intake of calories and other nutrients than full-term infants. The American Academy of Pediatrics recommends 105 to 130 kcal/kg/day. Breast milk from the infant’s mother is considered the ideal enteral nutrition for the infant. Several commercial formulas are designed for preterm infants.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 345

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. While a mother is feeding her high-risk neonate, the nurse observes the neonate having occasional apnea, pallor, and bradycardia. What is the most appropriate nursing action?
a. Let the neonate rest before breastfeeding again.
b. Resume gavage feedings until the neonate is asymptomatic.
c. Recognize that this may indicate an underlying illness.
d. Use a high-flow, pliable nipple because it requires less energy to use.

 

 

ANS:  C

Apnea, pallor, and bradycardia may be signs of an underlying illness. The infant should be evaluated to ensure he or she is not developing problems. The infant can rest while waiting for the evaluation. If the child is becoming ill, the capacity to digest enteral feedings may be compromised. The type of nipple that is being used should not produce the signs being observed.

 

DIF:    Cognitive Level: Applying              REF:   p. 347

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A preterm infant who is being fed commercial formula by gavage has had an increase in gastric residuals, abdominal distention, and apneic episodes. Which is the most appropriate nursing action?
a. Notify the practitioner.
b. Reduce the amount fed by gavage.
c. Feed human milk by gavage.
d. Feed only a glucose solution until the infant stabilizes.

 

 

ANS:  A

These are signs that may indicate early necrotizing enterocolitis. The practitioner is notified for further evaluation. Enteral feedings are usually stopped until the cause of increased residuals is identified.

 

DIF:    Cognitive Level: Applying              REF:   p. 347

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A mother planned to breastfeed her infant before giving birth at 33 weeks of gestation. The infant is stable and receiving oxygen. What is the most appropriate nursing action related to this?
a. Assist the mother in expressing breast milk.
b. Assess the infant’s readiness to breastfeed.
c. Explain to the mother that the infant is too small to receive breast milk.
d. Reassure the mother that infant formula is a good alternative to breastfeeding.

 

 

ANS:  B

Research confirms that human milk is the best source of nutrition for term and preterm infants. Preterm infants should be breastfed as soon as they have adequate sucking and swallowing reflexes and no other complications such as respiratory complications or concurrent illnesses. If the infant has adequate sucking and swallowing, the infant should breastfeed for some of the feedings. The mother can express milk to be used in her absence.

 

DIF:    Cognitive Level: Applying              REF:   p. 348

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A preterm neonate has begun breastfeeding, but the infant tires easily and has weak sucking and swallowing reflexes. What is the most appropriate nursing intervention?
a. Encourage the mother to breastfeed.
b. Resume orogastric feedings of formula.
c. Try nipple feeding the preterm infant formula.
d. Feed the remainder of breast milk by the orogastric route.

 

 

ANS:  D

If a preterm infant tires easily or has weak sucking when breastfeeding is initiated, the nurse should feed the additional breast milk by the enteral route. The nurse supports the mother in the attempts to breastfeed and ensures that the infant is receiving adequate nutrition. Breast milk should be used as long as the mother can supply it.

 

DIF:    Cognitive Level: Applying              REF:   p. 350

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A preterm infant is being fed by gavage. What is an important consideration for this infant?
a. Warm the feeding to body temperature before feeding.
b. Feed the infant in an isolette to minimize handling.
c. Provide a pacifier for nonnutritive sucking during bolus feeding.
d. Do not allow the infant to have increased stress by becoming hungry.

 

 

ANS:  C

Nonnutritive sucking during feedings will help the infant associate sucking with food. This can minimize feeding resistance and aversion. Warming the feeding to body temperature is not necessary. The food can be at room temperature. If possible, the infant should be held in a feeding position. The infant should be allowed to become hungry so that the food and nonnutritive sucking are associated with satisfying the hunger.

 

DIF:    Cognitive Level: Applying              REF:   p. 347

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. Which is an important nursing action related to the use of tape or adhesives on premature neonates?
a. Avoid using tape and adhesives until skin is more mature.
b. Remove adhesives with water, mineral oil, or petrolatum.
c. Use scissors carefully to remove tape instead of pulling off the tape.
d. Use solvents to remove tape and adhesives instead of pulling on the skin.

 

 

ANS:  B

Warm water, mineral oil, or petrolatum can facilitate the removal of adhesive. In a premature neonate, often it is impossible to avoid using adhesives and tape. The smallest amount of adhesive necessary should be used. Scissors should not be used to remove dressings or tape from very small and immature infants because it is easy to snip off tiny extremities or nick loosely attached skin. Solvents should be avoided because they tend to dry and burn the delicate skin.

 

DIF:    Cognitive Level: Applying              REF:   p. 351

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is caring for a 3-week-old boy born at 29 weeks of gestation. While taking vital signs and changing his diaper after stooling, the nurse observes his color is pink but slightly mottled, his arms and legs are limp and extended, he has the hiccups, his respirations are deep and rapid, and his heart rate is regular and rapid. The nurse should recognize these behaviors as signs of what?
a. Stress
b. Subtle seizures
c. Preterm behaviors
d. Onset of respiratory distress

 

 

ANS:  A

These are signs of stress or fatigue in a newborn. Neonatal seizures usually have some type of repetitive movement, from twitching to rhythmic jerking movements. The behavior of a preterm infant may be inactive and listless. Respiratory distress is exhibited by retractions and nasal flaring.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 354

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. The nurse knows that during deep sleep the neonate should not be disturbed if possible. Characteristics of deep sleep include what?
a. Regular breathing
b. Occasional smiling
c. Rapid eye movements
d. Apneic pauses of less than 20 seconds

 

 

ANS:  A

Regular breathing is characteristic of deep sleep. During active sleep, irregular breathing may be present. Occasional smiling, rapid eye movements, and apneic pauses of less than 20 seconds are characteristic of active sleep.

 

DIF:    Cognitive Level: Understanding     REF:   p. 355

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is providing care to a preterm infant. Which characteristic of daily care should be considered supportive?
a. Coordinated with parental visiting times
b. Given on a fixed schedule to ensure needs are met
c. Provided when infant’s heart rate is at its lowest level
d. Directed toward development of sleep organization

 

 

ANS:  D

Developmentally supportive care uses both behavioral and physiologic information as the basis of caregiving. A focus in preterm infants is to be alert for infant behavioral states and intervene during alert times. The parents should be taught how to recognize the infant’s behavioral states. Infants sleep for approximately 1 1/2 hours. The parents can provide care when the infant is awake. Care should not be delivered on a fixed schedule. It should always be responsive to the infant’s cues. The heart rate is at its lowest when the infant is in a sleep period. The infant should not be disturbed during this time if possible.

 

DIF:    Cognitive Level: Applying              REF:   p. 355

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. What can stroking infants who are physiologically unstable result in?
a. Fewer sleep periods
b. Increased weight gain
c. Shortened hospital stay
d. Decreased oxygen saturation

 

 

ANS:  D

Tactile interventions can have both positive and negative effects on neonates. For physiologically unstable infants and those who are disturbed during sleep, outcomes such as gasping, grunting, decreased oxygen saturation, apnea, and bradycardia have been observed. Fewer sleep periods are not associated with tactile stimulation in physiologically unstable infants. Increased weight gain and shortened hospital stays are positive outcomes that are observed when tactile stimulation is done at developmentally supportive times.

 

DIF:    Cognitive Level: Applying              REF:   p. 356

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. In about 1 week, a stable preterm infant will be discharged. The nurse should teach the parents to place the infant in which position for sleep?
a. Prone
b. Supine
c. Position of comfort
d. Abdomen with head elevated

 

 

ANS:  B

The American Academy of Pediatrics recommends that healthy infants be placed to sleep in a nonprone position. The prone position is associated with sudden infant death syndrome but can be used for supervised play.

 

DIF:    Cognitive Level: Applying              REF:   p. 357

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is planning care for a family expecting their newborn infant to die because of an incurable birth defect. What should the nurse’s interventions be based on?
a. Tangible remembrances of the infant (e.g., lock of hair, picture) prolong grief.
b. Photographs of infants should not be taken after death.
c. Funerals are not recommended because the mother is still recovering from childbirth.
d. The parents should be given the opportunity to “parent” the infant, including seeing, holding, touching, or talking to the infant in private.

 

 

ANS:  D

Providing care for the neonate is an important step in the grieving process. It gives the parents a tangible person for whom to grieve, which is a key component of the grieving process. Tangible remembrances and photographs can make the infant seem more real to the parents. Many neonatal intensive care units make bereavement memory packets, which may include a lock of hair, handprints, footprints, a bedside name card, and other individualized objects. Families need to be informed of their options. The ritual of a funeral provides an opportunity for the parents to be supported by relatives and friends.

 

DIF:    Cognitive Level: Applying              REF:   p. 360            TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. The nurse has been caring for an infant who has just died. The parents are present but appear to be “afraid” to hold the dead infant. What is the most appropriate nursing intervention?
a. Tell them there is nothing to fear.
b. Insist that they hold the infant “one last time.”
c. Respect their wishes and release the body to the morgue.
d. Keep the infant’s body available for a few hours in case they change their minds.

 

 

ANS:  D

When the parents are hesitant about holding and touching their infant, the nurse should wrap the infant in blankets and keep the infant’s body on the unit for a few hours. Many parents change their minds after the initial shock of the infant’s death. This will provide the parents time to see and hold their infant if they desire. Telling the parents there is nothing to fear minimizes the parents’ feelings. The nurse should allow the family to parent their child as they wish in death, as in life.

 

DIF:    Cognitive Level: Applying              REF:   p. 363

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Psychosocial Integrity

 

  1. The parents of an infant who has just died decide they want to hold the infant after their infant has gone to the morgue. What is the most appropriate nursing intervention at this time?
a. Explain gently that this is no longer possible.
b. Encourage the parents to accept the loss of their infant.
c. Offer to take a photograph of their infant because they cannot hold the infant.
d. Have the infant brought back to the unit, wrapped in a blanket, and rewarmed in a radiant warmer.

 

 

ANS:  D

The parents should be allowed to hold their infant in the hospital setting. The infant’s body should be retrieved and rewarmed in a radiant warmer. The nurse should provide a private place where the parents can hold their child for a final time. If possible, to facilitate the parents’ grieving, the nurse should bring the infant back to the unit. A photograph is an excellent idea, but it does not replace the parents’ need to hold the child.

 

DIF:    Cognitive Level: Applying              REF:   p. 363

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Psychosocial Integrity

 

  1. Which statement best describes the characteristics of preterm infants?
a. Thermoregulation is well established.
b. Extremities remain in attitude of flexion.
c. Sucking reflex is absent, weak, or ineffectual.
d. The head is proportionately small in relation to the body.

 

 

ANS:  C

Reflex activity is only partially developed. Sucking is absent, weak, or ineffectual. Thermoregulation is poorly developed, and a preterm infant needs to be in a neutral thermal environment. A preterm infant may be listless and inactive compared with the overall attitude of flexion and activity of a full-term infant. A preterm infant’s head is proportionately larger than the body.

 

DIF:    Cognitive Level: Understanding     REF:   p. 365

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which is a characteristic of postmature infants?
a. Abundant lanugo
b. Lack of scalp hair
c. Plump appearance
d. Parchment-like skin

 

 

ANS:  D

In postterm infants, the skin is often cracked, parchment-like, and desquamating. Lanugo is usually absent. Scalp hair is usually abundant. Subcutaneous fat is usually depleted, giving the child a thin, elongated appearance.

 

DIF:    Cognitive Level: Understanding     REF:   p. 365

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which is a central factor responsible for respiratory distress syndrome in a newborn?
a. Absence of alveoli
b. Immature bronchioles
c. Overdeveloped alveoli
d. Deficient surfactant production

 

 

ANS:  D

The successful adaptation to extrauterine breathing requires numerous factors, which most term infants successfully accomplish. Preterm infants with respiratory distress are not able to adjust. The most likely central cause is the abnormal development of the surfactant system. The number and state of development of the alveoli are not central factors in respiratory distress syndrome. The instability of the alveoli related to the lack of surfactant is the causative issue. The bronchioles are sufficiently developed in newborns.

 

DIF:    Cognitive Level: Understanding     REF:   p. 368

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. A preterm infant of 33 weeks of gestation is admitted to the neonatal intensive care unit. Approximately 2 hours after birth, the neonate begins having difficulty breathing, with grunting, tachypnea, and nasal flaring. What should the nurse recognize?
a. This is a normal finding.
b. Further evaluation is needed.
c. Improvement should occur within 24 hours.
d. This is not significant unless cyanosis is present.

 

 

ANS:  B

These are signs of respiratory distress syndrome and require further evaluation. There is no way to predict the infant’s clinical course based on the available data. Cyanosis may be present, but these are significant findings indicative of respiratory distress even without cyanosis.

 

DIF:    Cognitive Level: Analyzing            REF:   pp. 375-376

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is caring for a preterm neonate who requires mechanical ventilation for treatment of respiratory distress syndrome. Because of the mechanical ventilation, the nurse should recognize an increased risk of what?
a. Pneumothorax
b. Transient tachypnea
c. Meconium aspiration
d. Retractions and nasal flaring

 

 

ANS:  A

Positive pressure introduced by mechanical apparatus has created an increase in the incidence of ruptured alveoli and subsequent pneumothorax and bronchopulmonary dysplasia. Tachypnea may be an indication of a pneumothorax, but it should not be transient. Meconium aspiration is not associated with mechanical ventilation. Retractions and nasal flaring are indications of the use of accessory muscles when the infant cannot obtain sufficient oxygen. The use of mechanical ventilation bypasses the infant’s need to use these muscles.

 

DIF:    Cognitive Level: Understanding     REF:   p. 375

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. What are possible premature infant complications from oxygen therapy and mechanical ventilation?
a. Bronchopulmonary dysplasia and retinopathy of prematurity
b. Anemia and necrotizing enterocolitis
c. Cerebral palsy and persistent patent ductus arteriosus
d. Congestive heart failure and cerebral edema

 

 

ANS:  A

Oxygen therapy, although lifesaving, is not without hazards. The positive pressure created by mechanical ventilation creates an increase in the number of ruptured alveoli and subsequent pneumothorax and bronchopulmonary dysplasia. Oxygen therapy puts the infant at risk for retinopathy of prematurity. Anemia, necrotizing enterocolitis, cerebral palsy, persistent patent ductus, congestive heart failure, and cerebral edema are not primarily caused by oxygen therapy and mechanical ventilation.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 381            TOP:   Nursing Process: Evaluation

MSC:  Client Needs: Physiological Integrity

 

  1. A preterm infant with respiratory distress syndrome is receiving inhaled nitric oxide (NO). What is the reason for administering the inhaled nitric oxide?
a. To mature the lungs
b. To deliver a level of oxygen that is safe
c. To increase the removal of pulmonary debris such as meconium
d. To reduce pulmonary vasoconstriction and pulmonary hypertension

 

 

ANS:  D

NO is used for infants with conditions such as meconium aspiration syndrome, pneumonia, sepsis, and congenital diaphragmatic hernia. Most infants with these disorders do have mature lungs. NO is not oxygen. Inhaled NO is beneficial for infants with meconium aspiration syndrome, but it does not work by removing debris. Inhaled NO is a significant treatment for infants with persistent pulmonary hypertension, pulmonary vasoconstriction, and subsequent acidosis and severe hypoxia. When inhaled into the lungs, it causes smooth muscle relaxation and reduction of pulmonary vasoconstriction and subsequent pulmonary hypertension.

 

DIF:    Cognitive Level: Understanding     REF:   p. 375            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is caring for a neonate with respiratory distress syndrome. The infant has an endotracheal tube. What should nursing considerations related to suctioning include?
a. Suctioning should not be carried out routinely.
b. The infant should be in the Trendelenburg position for suctioning.
c. Routine suctioning, usually every 15 minutes, is necessary.
d. Frequent suctioning is necessary to maintain the patency of the bronchi.

 

 

ANS:  A

Suctioning is not an innocuous procedure and can cause bronchospasm, bradycardia, hypoxia, and increased intracranial pressure (ICP). It should never be carried out routinely. The Trendelenburg position should be avoided because it can contribute to increased ICP and reduced lung capacity from gravity pushing the organs against the diaphragm.

 

DIF:    Cognitive Level: Applying              REF:   p. 376

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. What signs should the nurse expect when a pneumothorax occurs in an infant on mechanical ventilation?
a. Tachycardia
b. Clear, distinct heart tones
c. Widened pulse pressure
d. Abrupt duskiness or cyanosis

 

 

ANS:  D

The early signs of a pneumothorax in an infant on mechanical ventilations include the abrupt onset of duskiness or cyanosis. Tachypnea is the presenting sign. Usually the heart rate is decreased. The heart sounds usually become muffled, diminished, or shifted. The pulse pressure decreases in pneumothorax.

 

DIF:    Cognitive Level: Understanding     REF:   p. 379

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. What is most descriptive of the signs observed in neonatal sepsis?
a. Seizures
b. Sudden hyperthermia
c. Decreased urinary output
d. Subtle, vague, and nonspecific physical signs

 

 

ANS:  D

The signs of neonatal sepsis are usually characterized by the infant generally “not doing well.” Poor temperature control, usually with hypothermia, lethargy, poor feeding, pallor, cyanosis or mottling, and jaundice, may be evident. Seizures are not a manifestation of sepsis. Severe neurologic sequelae may occur in low–birth-weight infants with sepsis. Hyperthermia is rare in neonatal sepsis. Urinary output is not affected by sepsis.

 

DIF:    Cognitive Level: Understanding     REF:   p. 384

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. What is the most common cause of iatrogenic anemia in preterm infants?
a. Frequent blood sampling
b. Respiratory distress syndrome
c. Meconium aspiration syndrome
d. Persistent pulmonary hypertension

 

 

ANS:  A

The most common cause of anemia in preterm infants is frequent blood-sample withdrawal and inadequate erythropoiesis in acutely ill infants. Microsamples should be used for blood tests, and the amount of blood drawn should be monitored. Respiratory distress syndrome, meconium aspiration syndrome, and persistent pulmonary hypertension are not causes of anemia. They may require frequent blood sampling, which contributes to the problem of decreased erythropoiesis and anemia.

 

DIF:    Cognitive Level: Understanding     REF:   p. 388

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. A newborn is diagnosed with retinopathy of prematurity. What should the nurse know about this condition?
a. Blindness cannot be prevented.
b. No treatment is currently available.
c. Cryotherapy and laser therapy are effective treatments.
d. Long-term administration of oxygen will be necessary.

 

 

ANS:  C

Cryotherapy and laser photocoagulation therapy can be used to minimize the vascular proliferation process that causes the retinal damage. Blindness can be prevented with early recognition and treatment. Long-term administration of oxygen is one of the causes. Oxygen should be used judiciously.

 

DIF:    Cognitive Level: Understanding     REF:   p. 389

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. What is a priority of care for an infant with an intraventricular hemorrhage?
a. Avoid use of analgesia.
b. Keep the infant’s head to the right side.
c. Minimize interventions that cause crying.
d. Encourage the staff and parents to hold the infant.

 

 

ANS:  C

The priority goal is to decrease intracranial pressure (ICP). Allowing the infant to cry will cause an increase in pressure. Analgesia is used as necessary to maintain the child pain free. This reduces ICP. The infant should be positioned with the body and head in the midline position. Turning the child’s head to the right side can cause cerebral venous congestion and increased ICP. The child should have minimum stimulation to avoid increases in ICP.

 

DIF:    Cognitive Level: Applying              REF:   p. 392

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. What is a characteristic of most neonatal seizures?
a. Clonic
b. Generalized
c. Well organized
d. Subtle and barely discernible

 

 

ANS:  D

Seizures in newborns may be subtle and barely discernible or grossly apparent. Most neonatal seizures are subcortical and do not have the etiologic or prognostic significance of seizures in older children. Clonic seizures are slow, rhythmic jerking movements. Generalized seizures are bilateral jerks of the upper and lower limbs that are associated with electroencephalographic discharges. Neonatal seizures are not well organized.

 

DIF:    Cognitive Level: Understanding     REF:   p. 393

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. What should the nurse anticipate in an infant who was exposed to cocaine during pregnancy?
a. Seizures
b. Hyperglycemia
c. Large for gestational age
d. Hypertonia and jitteriness

 

 

ANS:  D

The nurse should anticipate neurobehavioral depression or excitability and implement care directed at the infant’s manifestations. Few or no neurologic sequelae appear in infants born to mothers who used cocaine during pregnancy. The infant is usually a poor feeder, so hypoglycemia should be more likely than hyperglycemia. The infant usually has intrauterine growth restriction.

 

DIF:    Cognitive Level: Understanding     REF:   p. 399

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. What does the nursing care for infants with fetal alcohol syndrome (FAS) include?
a. Nutritional guidance
b. An intensive stimulation program
c. Facilitation of improvement in cardiovascular status
d. An individualized program based on maternal alcohol consumption

 

 

ANS:  A

Infants with FAS have characteristic poor feeding behaviors that persist throughout childhood. The nurse assists in devising strategies to improve nutrition. The infant is protected from overstimulation. FAS does not include cardiovascular problems. The effects of FAS do not depend on the quantity of maternal alcohol consumption.

 

DIF:    Cognitive Level: Applying              REF:   p. 401

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. Women who smoke during pregnancy are most likely to have infants who are what?
a. Large for gestational age
b. Preterm but size appropriate for gestational age
c. Growth restricted in weight only
d. Growth restricted in weight, length, and chest and head circumference

 

 

ANS:  D

Infants born to mothers who smoke have retardation in all aspects of growth. Infants of mothers with diabetes are large for gestational age. Infants of mothers who smoke are small for gestational age.

 

DIF:    Cognitive Level: Understanding     REF:   p. 401

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. An infant of a mother with herpes simplex infection has just been born. What should nursing considerations include?
a. The infant should be isolated in a nursery.
b. No special precautions are necessary.
c. The mother and infant should be together in a private room.
d. Immediate discharge is indicated to prevent spread of infection.

 

 

ANS:  C

The herpes virus can be transmitted to the infant intrapartum or by direct contact. The mother and infant should room together in a private room to reduce the risk of transmission to other infants and mothers. The infant should be kept with the mother. Placement in the nursery creates the possibility of transmission of the virus. Immediate discharge is not necessary. Good handwashing and a private room will minimize the risk of transmission while allowing the mother and infant to receive postpartum care.

 

DIF:    Cognitive Level: Applying              REF:   p. 402            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is caring for a newborn who was born at 35 weeks of gestation and is considered a late preterm infant. What intervention should be included in the infant’s care plan?
a. Feed the infant dextrose water as the first feeding after 12 hours.
b. Promote skin-to-skin care in the immediate postpartum period.
c. Avoid administration of the hepatitis B vaccine until after discharge.
d. Delay the newborn screening and hearing test until the infant is at 40 weeks’ corrected age.

 

 

ANS:  B

Late preterm infants can usually tolerate skin-to-skin care in the immediate postpartum period, which enhances the bonding process with the parents. A late preterm infant should be given an early feeding of human milk or formula; dextrose water is not required for the first feeding. The hepatitis B vaccine and all newborn screening, including the hearing test, should be done before discharge, with no limitation on corrected age.

 

DIF:    Cognitive Level: Applying              REF:   p. 337

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is caring for a preterm infant who is receiving caffeine citrate for treatment of apnea of prematurity. What signs should indicate caffeine toxicity?
a. Bradycardia and hypotension
b. Oliguria and sleepiness
c. Vomiting and irritability
d. Constipation and weight loss

 

 

ANS:  C

Caffeine citrate is the medication of choice for the treatment of apnea of prematurity because it has fewer side effects, requires once-daily dosing, has slower elimination, and has a wider therapeutic range than other options. Caffeine toxicity can still occur, so the preterm infant needs to be monitored for signs of toxicity, including vomiting and irritability. Bradycardia, hypotension, oliguria, sleepiness, constipation, and weight loss are not symptoms of toxicity.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 368

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is attending a delivery of a full-term infant with meconium noted in the amniotic fluid. The nurse should understand that what action should be performed in the delivery room?
a. The infant will be suctioned with a DeLee trap suctioning device after delivery of the head while the chest is still compressed in the birth canal.
b. The infant’s nose will be suctioned at the delivery of the head; subsequent suctioning of the mouth will occur after completion of the delivery.
c. The infant will need to take the first breath after delivery of the head and shoulders and will require tracheal suctioning.
d. The infant’s mouth, nose, and posterior pharynx will be suctioned just after the head is delivered while the chest is still compressed in the birth canal.

 

 

ANS:  D

Meconium aspiration syndrome can occur when a fetus is subjected to intrauterine stress that causes relaxation of the anal sphincter and passage of meconium into the amniotic fluid, and the meconium-stained fluid is aspirated with the first breath. To prevent meconium aspiration, the infant’s mouth, nose, and posterior pharynx should be suctioned just after delivery of the head while the chest is still compressed in the birth canal. A DeLee trap is no longer used in the delivery room. The infant’s mouth should be suctioned before the nose and during the delivery, not at the completion of delivery. The infant should not take its first breath without suctioning first and may or may not require tracheal suctioning.

 

DIF:    Cognitive Level: Applying              REF:   p. 376            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is placing an infant in a servocontrol radiant warmer. The nurse should attach the temperature probe to which area of the infant’s body?
a. Scapula
b. Sternum
c. Abdomen
d. Front of the lower leg

 

 

ANS:  C

The temperature probe should be placed over a nonbony, well-perfused tissue area such as the abdomen or flank. The scapula, sternum, and front of the lower leg would be a bony area.

 

DIF:    Cognitive Level: Applying              REF:   p. 342

TOP:   Nursing Process: Implementation

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. The nurse is preparing to administer a gavage feeding to an infant. The nurse should place the infant in which position for the feeding?
a. Supine with the head flat
b. Sitting upright in a car seat
c. Left side-lying with the head flat
d. Prone with the head slightly elevated

 

 

ANS:  D

The gavage feeding is best performed when an infant is in a prone or a right side-lying position with the head slightly elevated. Supine and left side-lying with the head flat would not be a recommended position. The infant should not be gavage fed sitting in a car seat.

 

DIF:    Cognitive Level: Applying              REF:   p. 347

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. The neonatal intensive care nurse is planning care for an infant in an incubator. Which interventions should the nurse plan to assure therapeutic visual stimulation for the neonate?
a. Use an incubator cover.
b. Keep lights bright in the unit.
c. Place a cloth over the infant’s face.
d. Leave a visual stimulus at the head of the infant’s bed.

 

 

ANS:  A

Decrease ambient light levels by using an incubator cover and by dimming lights, not keeping them bright. Avoid placing a cloth over the face because it will cause tactile irritation. Avoid leaving visual stimuli in the beds of infants who cannot escape from it.

 

DIF:    Cognitive Level: Applying              REF:   p. 359            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Parents of an infant born at 36 weeks’ gestation ask the nurse, “Will our infant need a car seat trial before being discharged?” What is the nurse’s best response?
a. “Yes, to see if the car seat is the appropriate size.”
b. “Yes, to determine if blanket rolls will be needed.”
c. “No, your infant was old enough at birth to not need a trial.”
d. “Yes, to monitor for possible apnea and bradycardia while in the seat.”

 

 

ANS:  D

It is recommended that infants younger than 37 weeks of gestation have a period of observation in an appropriate car seat to monitor for possible apnea and bradycardia. The trial is not done to check the size of the car seat or to determine if blanket rolls will be needed. The infant was born at 36 weeks of gestation, so it is recommended to perform a car sear trial.

 

DIF:    Cognitive Level: Applying              REF:   p. 362

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is caring for an infant born at 37 weeks of gestation of a nondiabetic mother just admitted to the neonatal intensive care unit for observation. The nurse notes that which lecithin/sphingomyelin (L/S) ratio obtained before delivery indicates no risk of respiratory distress syndrome (RDS)?
a. 1.4:1
b. 1.6:1
c. 1.8:1
d. 2:1

 

 

ANS:  D

An L/S ratio of 2:1 in nondiabetic mothers indicates virtually no risk of RDS.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 372

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. The health care provider has prescribed surfactant, beractant (Survanta), to be administered to an infant with respiratory distress syndrome (RDS). The nurse understands that the beractant will be administered by which route?
a. Orally
b. Intravenously
c. Via the ET tube
d. Intramuscularly

 

 

ANS:  C

Surfactant is administered via the ET tube directly into the infant’s trachea.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 373            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

MULTIPLE RESPONSE

 

  1. The nurse is monitoring an infant’s temperature to avoid cold stress. The nurse understands that cold stress in the infant can cause which complications? (Select all that apply.)
a. Hypoxia
b. Hypoglycemia
c. Metabolic acidosis
d. Respiratory alkalosis
e. Increased shivering response

 

 

ANS:  A, B, C

Cold stress poses hazards to the neonate through hypoxia, metabolic acidosis, and hypoglycemia. Cold stress does not cause respiratory alkalosis. The infant lacks a shivering response, so it is not a complication of cold stress.

 

DIF:    Cognitive Level: Understanding     REF:   p. 342

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. The neonatal intensive care nurse is caring for a neonate born at 36 weeks of gestation in an incubator. Which actions should the nurse plan to assure adequate skin care for the neonate? (Select all that apply.)
a. Changing any adhesives every 12 hours
b. Removing adhesives or skin barriers slowly
c. Using an adhesive remover when removing tape
d. Applying emollient as needed for dry, flaking skin
e. Using cleanser or soaps no more than two or three times a week

 

 

ANS:  B, D, E

Skin care for the neonate involves removing adhesive or skin barriers slowly, supporting the skin underneath with one hand and gently peeling away from the skin with the other hand. Emollient should be applied as needed for dry, flaking skin, and cleansers or soaps should be used no more than two or three times a week because they can dry the skin. Adhesive remover, solvents, and bonding agents should be avoided. Adhesives should not be removed for at least 24 hours after application, not 12.

 

DIF:    Cognitive Level: Applying              REF:   p. 352            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is positioning a preterm neonate. What are therapeutic positions the nurse should implement? (Select all that apply.)
a. Elbows extended
b. Hands at the side
c. Neutral or slightly flexed neck
d. Trunk slightly rounded with pelvic tilt
e. Hips partially flexed and adducted to near midline

 

 

ANS:  C, D, E

Therapeutic positioning of the neonate includes a neutral or slightly flexed neck and the trunk slightly rounded with the pelvis tilted and hips partially flexed and adducted to near midline. The elbows should be flexed, not extended, and the hands should be brought to the face or midline as the position allows, not by the side.

 

DIF:    Cognitive Level: Applying              REF:   p. 357

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is caring for a neonate on positive-pressure ventilation. The nurse monitors for which complications of positive-pressure ventilation? (Select all that apply.)
a. Pneumothorax
b. Pneumomediastinum
c. Respiratory distress syndrome
d. Meconium aspiration syndrome
e. Pulmonary interstitial emphysema

 

 

ANS:  A, B, E

Positive-pressure introduced by mechanical apparatus increases complications such as pulmonary interstitial emphysema, pneumothorax, and pneumomediastinum. Respiratory distress syndrome and meconium aspiration syndrome are not complications of positive-pressure ventilation.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 375

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. The home care nurse is visiting a 6-month-old infant with bronchopulmonary dysplasia (BPD). The nurse assesses the child for which signs of overhydration? (Select all that apply.)
a. Edema
b. Serum sodium of 140 mEq/L
c. Urine specific gravity of 1.008
d. Weight gain of 1 lb in 1 week

 

 

ANS:  A, D

Nurses must be alert to signs of overhydration in an infant with BPD such as changes in weight, electrolytes, output measurements, and urine specific gravity and signs of edema. Six-month-old infants gain around 4 to 5 oz a week. One pound in 1 week would indicate fluid retention. Serum sodium of 140 mEq/L and urine specific gravity of 1.008 are normal values and indicate adequate fluid balance.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 383

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is caring for a neonate with an intraventricular hemorrhage. What interventions should the nurse avoid to prevent any increase in intracranial pressure? (Select all that apply.)
a. Keeping the head of the bed flat
b. Keeping the environment quiet
c. Handling the neonate minimally
d. Suctioning the endotracheal tube frequently
e. Maintaining the neonate’s head in a midline position

 

 

ANS:  A, D

Some nursing procedures increase intracranial pressure (ICP). For example, blood pressure increases significantly during endotracheal suctioning in preterm infants, and head positioning produces measurable changes in ICP. ICP is highest when infants are in the dependent (flat) position and decreases when the head is in a midline position and elevated 30 degrees. Keeping the environment quiet, handling the neonate minimally, and maintaining the neonate’s head in a midline position are measures to keep the ICP down.

 

DIF:    Cognitive Level: Applying              REF:   p. 392

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is admitting a drug-exposed newborn to the neonatal intensive care unit. The nurse should assess the newborn for which signs of withdrawal? (Select all that apply.)
a. Tremors
b. Nasal stuffiness
c. Loose, watery stools
d. Hypoactive Moro reflex
e. Decrease in respiratory rate

 

 

ANS:  A, B, C

Signs of withdrawal in a drug-exposed newborn include increased tone; increased respiratory rate; disturbed sleep; fever; excessive sucking; and loose, watery stools. Other signs observed included projectile vomiting, mottling, crying, nasal stuffiness, hyperactive Moro reflex, and tremors.

 

DIF:    Cognitive Level: Applying              REF:   p. 396

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. The nurse is teaching parents of a bottle-fed preterm infant techniques to facilitate feeding. Which techniques should the nurse include? (Select all that apply.)
a. Choose a soft nipple.
b. Avoid arousing the infant.
c. Recognize the infant’s limits.
d. Prepare a calm, quiet area for the feeding.
e. Ensure a restful environment between feedings.

 

 

ANS:  C, D, E

Feeding facilitation techniques for preterm infants include recognizing the infant’s limits; preparing a calm, quiet area for the feeding; and ensuring a restful environment between feedings. Using a firm nipple with slower flow and gently arousing the infant for the feeding are other facilitation techniques. Using a soft nipple and avoiding arousing the infant are techniques that would not facilitate feeding.

 

DIF:    Cognitive Level: Applying              REF:   p. 349

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

Chapter 11: Health Problems of the Infant

 

MULTIPLE CHOICE

 

  1. Rickets is caused by a deficiency in what?
a. Vitamin A
b. Vitamin C
c. Folic acid and iron
d. Vitamin D and calcium

 

 

ANS:  D

Fat-soluble vitamin D and calcium are necessary in adequate amounts to prevent rickets. No correlation exists between rickets and folic acid, iron, or vitamins A and C.

 

DIF:    Cognitive Level: Remembering      REF:   p. 452

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. Which factors will decrease iron absorption and should not be given at the same time as an iron supplement?
a. Milk
b. Fruit juice
c. Multivitamin
d. Meat, fish, poultry

 

 

ANS:  A

Many foods interfere with iron absorption and should be avoided when iron is consumed. These foods include phosphates found in milk, phytates found in cereals, and oxalates found in many vegetables. Vitamin C–containing juices enhance the absorption of iron. Multivitamins may contain iron; no contraindication exists to taking the two together. Meat, fish, and poultry do not affect absorption.

 

DIF:    Cognitive Level: Understanding     REF:   p. 454            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is helping parents achieve a more nutritionally adequate vegetarian diet for their children. Which is most likely lacking in their particular diet?
a. Fat
b. Protein
c. Vitamins C and A
d. Iron and calcium

 

 

ANS:  D

Deficiencies can occur when various substances in the diet interact with minerals. For example, iron, zinc, and calcium can form insoluble complexes with phytates or oxalates (substances found in plant proteins), which impair the bioavailability of the mineral. This type of interaction is important in vegetarian diets because plant foods such as soy are high in phytates. Fat and vitamins C and A are readily available from vegetable sources. Plant proteins are available.

 

DIF:    Cognitive Level: Applying              REF:   p. 454

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity

 

  1. A 1-year-old child is on a pure vegetarian (vegan) diet. This diet requires supplementation with what?
a. Niacin
b. Folic acid
c. Vitamins D and B12
d. Vitamins C and E

 

 

ANS:  C

Pure vegetarian (vegan) diets eliminate any food of animal origin, including milk and eggs. These diets require supplementation with many vitamins, especially vitamin B6, vitamin B12, riboflavin, vitamin D, iron, and zinc. Niacin, folic acid, and vitamins C and E are readily obtainable from foods of vegetable origin.

 

DIF:    Cognitive Level: Applying              REF:   p. 453            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. What is marasmus?
a. Deficiency of protein with an adequate supply of calories
b. Syndrome that results solely from vitamin deficiencies
c. Not confined to geographic areas where food supplies are inadequate
d. Characterized by thin, wasted extremities and a prominent abdomen resulting from edema (ascites)

 

 

ANS:  C

Marasmus is a syndrome of emotional and physical deprivation. It is not confined to geographic areas were food supplies are inadequate. Marasmus is characterized by gradual wasting and atrophy of body tissues, especially of subcutaneous fat. The child appears old, with flabby and wrinkled skin. Marasmus is a deficiency of both protein and calories.

 

DIF:    Cognitive Level: Understanding     REF:   p. 456

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. At a well-child check-up, the nurse notes that an infant with a previous diagnosis of failure to thrive (FTT) is now steadily gaining weight. The nurse should recommend that fruit juice intake be limited to no more than how much?
a. 4 oz/day
b. 6 oz/day
c. 8 oz/day
d. 12 oz/day

 

 

ANS:  A

Restrict juice intake in children with FTT until adequate weight gain has been achieved with appropriate milk sources; thereafter, give no more than 4 oz/day of juice.

 

DIF:    Cognitive Level: Understanding     REF:   p. 465            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. An infant has been diagnosed with an allergy to milk. In teaching the parent how to meet the infant’s nutritional needs, the nurse states that
a. Most children will grow out of the allergy.
b. All dairy products must be eliminated from the child’s diet.
c. It is important to have the entire family follow the special diet.
d. Antihistamines can be used so the child can have milk products.

 

 

ANS:  A

Approximately 80% of children with cow’s milk allergy develop tolerance by the fifth birthday. The child can have eggs. Any food that has milk as a component or filler is eliminated. These foods include processed meats, salad dressings, soups, and milk chocolate. Having the entire family follow the special diet would provide support for the child, but the nutritional needs of other family members must be addressed. Antihistamines are not used for food allergies.

 

DIF:    Cognitive Level: Applying              REF:   p. 460

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity

 

  1. Lactose intolerance is diagnosed in an 11-month-old infant. Which should the nurse recommend as a milk substitute?
a. Yogurt
b. Ice cream
c. Fortified cereal
d. Cow’s milk–based formula

 

 

ANS:  A

Yogurt contains the inactive lactase enzyme, which is activated by the temperature and pH of the duodenum. This lactase activity substitutes for the lack of endogenous lactase. Ice cream and cow’s milk–based formula contain lactose, which will probably not be tolerated by the child. Fortified cereal does not have the nutritional equivalents of milk.

 

DIF:    Cognitive Level: Applying              REF:   p. 462

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity

 

  1. Which term refers to the relative lactase deficiency observed in preterm infants of less than 34 weeks of gestation?
a. Congenital lactase deficiency
b. Primary lactase deficiency
c. Secondary lactase deficiency
d. Developmental lactase deficiency

 

 

ANS:  D

Developmental lactase deficiency refers to the relative lactase deficiency observed in preterm infants of less than 34 weeks of gestation. Congenital lactase deficiency occurs soon after birth after the newborn has consumed lactose-containing milk. Primary lactase deficiency, sometimes referred to as late-onset lactase deficiency, is the most common type of lactose intolerance and is manifested usually after 4 or 5 years of age. Secondary lactase deficiency may occur secondary to damage of the intestinal lumen, which decreases or destroys the enzyme lactase.

 

DIF:    Cognitive Level: Understanding     REF:   p. 462

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. Which statement best describes colic?
a. Periods of abdominal pain resulting in weight loss
b. Usually the result of poor or inadequate mothering
c. Periods of abdominal pain and crying occurring in infants older than age 6 months
d. A paroxysmal abdominal pain or cramping manifested by episodes of loud crying

 

 

ANS:  D

Colic is described as paroxysmal abdominal pain or cramping that is manifested by loud crying and drawing up the legs to the abdomen. Weight loss is not part of the clinical picture. There are many theories about the cause of colic. Emotional stress or tension between the parent and child is one component. This is not consistent throughout all cases. Colic is most common in infants younger than 3 months of age.

 

DIF:    Cognitive Level: Understanding     REF:   p. 470

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. The parent of an infant with colic tells the nurse, “All this baby does is scream at me; it is a constant worry.” What is the nurse’s best action?
a. Encourage the parent to verbalize feelings.
b. Encourage the parent not to worry so much.
c. Assess the parent for other signs of inadequate parenting.
d. Reassure the parent that colic rarely lasts past age 9 months.

 

 

ANS:  A

Colic is multifactorial, and no single treatment is effective for all infants. The parent is verbalizing concern and worry. The nurse should allow the parent to put these feelings into words. An empathetic, gentle, and reassuring attitude, in addition to suggestions about remedies, will help alleviate the parent’s anxiety. The nurse should reassure the parent that he or she is not doing anything wrong. The infant with colic is experiencing spasmodic pain that is manifested by loud crying, in some cases up to 3 hours each day. Telling the parent that it will eventually go away does not help him or her through the current situation.

 

DIF:    Cognitive Level: Applying              REF:   p. 479            TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. What may a clinical manifestations of failure to thrive (FTT) in a 13-month-old include?
a. Irregularity in activities of daily living
b. Preferring solid food to milk or formula
c. Weight that is at or below the 10th percentile
d. Appropriate achievement of developmental landmarks

 

 

ANS:  A

One of the clinical manifestations of children with FTT is irregularity or low rhythmicity in activities of daily living. Children with FTT often refuse to switch from liquids to solid foods. Weight below the fifth percentile is indicative of FTT. Developmental delays, including social, motor, adaptive, and language, exist.

 

DIF:    Cognitive Level: Understanding     REF:   p. 462

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. Which one of the following strategies might be recommended for an infant with failure to thrive (FTT) to increase caloric intake?
a. Vary the schedule for routine activities on a daily basis.
b. Be persistent through 10 to 15 minutes of food refusal.
c. Avoid solids until after the bottle is well accepted.
d. Use developmental stimulation by a specialist during feedings.

 

 

ANS:  B

Calm perseverance through 10 to 15 minutes of food refusal will eventually diminish negative behavior. Children with FTT need a structured routine to help establish rhythmicity in their activities of daily living. Many children with FTT are fed exclusively from a bottle. Solids should be fed first. Stimulation is reduced during mealtimes to maintain the focus on eating.

 

DIF:    Cognitive Level: Understanding     REF:   p. 465

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is examining an infant, age 10 months, who was brought to the clinic for persistent diaper rash. The nurse finds perianal inflammation with satellite lesions. What is the most likely cause?
a. Impetigo
b. Urine and feces
c. Candida albicans infection
d. Infrequent diapering

 

 

ANS:  C

  1. albicans infection produces perianal inflammation and a maculopapular rash with satellite lesions that may cross the inguinal folds. Impetigo is a bacterial infection that spreads peripherally in sharply marginated, irregular outlines. Eruptions involving the skin in contact with the diaper but sparing the folds are likely to be caused by chemical irritation, especially urine and feces, and may be related to infrequent diapering.

 

DIF:    Cognitive Level: Understanding     REF:   p. 466

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. A new parent asks the nurse, “How can diaper rash be prevented?” What should the nurse recommend?
a. Wash the infant with soap before applying a thin layer of oil.
b. Clean the infant with soap and water every time diaper is changed.
c. Wipe stool from the skin using water and a mild cleanser.
d. When changing the diaper, wipe the buttocks with oil and powder the creases.

 

 

ANS:  C

Change the diaper as soon as it becomes soiled. Gently wipe stool from the skin with water and mild soap. The skin should be thoroughly dried after washing. Applying oil does not create an effective barrier. Over washing the skin should be avoided, especially with perfumed soaps or commercial wipes, which may be irritating. Baby powder should not be used because of the danger of aspiration.

 

DIF:    Cognitive Level: Applying              REF:   p. 467

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity

 

  1. What is most descriptive of atopic dermatitis (AD) (eczema) in an infant?
a. Easily cured
b. Worse in humid climates
c. Associated with hereditary allergies
d. Related to upper respiratory tract infections

 

 

ANS:  C

AD is a type of pruritic eczema that usually begins during infancy and is associated with allergy with a hereditary tendency. Approximately 50% of children with AD develop asthma. AD can be controlled but not cured. Manifestations of the disease are worse when environmental humidity is lower. AD is not associated with respiratory tract infections.

 

DIF:    Cognitive Level: Understanding     REF:   p. 468

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. Where do eczematous lesions most commonly occur in an infant?
a. Abdomen, cheeks, and scalp
b. Buttocks, abdomen, and scalp
c. Back and flexor surfaces of the arms and legs
d. Cheeks and extensor surfaces of the arms and legs

 

 

ANS:  D

The lesions of atopic dermatitis are generalized in infants. They are most common on the cheeks, scalp, trunk, and extensor surfaces of the extremities. The abdomen and buttocks are not common sites of lesions. The back and flexor surfaces are not usually involved.

 

DIF:    Cognitive Level: Understanding     REF:   p. 468

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is discussing the management of atopic dermatitis (eczema) with a parent. What should be included?
a. Dress infant warmly to prevent chilling.
b. Keep the infant’s fingernails and toenails cut short and clean.
c. Give bubble baths instead of washing lesions with soap.
d. Launder clothes in mild detergent; use fabric softener in the rinse.

 

 

ANS:  B

The infant’s nails should be kept short and clean and have no sharp edges. Gloves or cotton socks can be placed over the child’s hands and pinned to the shirt sleeves. Heat and humidity increase perspiration, which can exacerbate the eczema. The child should be dressed properly for the climate. Synthetic material (not wool) should be used for the child’s clothing during cold months. Baths are given as prescribed with tepid water, and emollients such as Aquaphor, Cetaphil, and Eucerin are applied within 3 minutes. Soap (except as indicated), bubble bath oils, and powders are avoided. Fabric softener should be avoided because of the irritant effects of some of its components.

 

DIF:    Cognitive Level: Applying              REF:   p. 469

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity

 

  1. The parents of a 3-month-old infant report that their infant sleeps supine (face up) but is often prone (face down) while awake. The nurse’s response should be based on remembering what?
a. This is acceptable to encourage head control and turning over.
b. This is acceptable to encourage fine motor development.
c. This is unacceptable because of the risk of sudden infant death syndrome (SIDS).
d. This is unacceptable because it does not encourage achievement of developmental milestones.

 

 

ANS:  A

These parents are implementing the guidelines to reduce the risk of SIDS. Infants should sleep on their backs to reduce the risk of SIDS and then be placed on their abdomens when awake to enhance achievement of milestones such as head control. These position changes encourage gross motor, not fine motor, development.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 473

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity

 

  1. After the introduction of the Back to Sleep campaign in 1992, an increased incidence has been noted of which pediatric issues?
a. Sudden infant death syndrome (SIDS)
b. Plagiocephaly
c. Failure to thrive
d. Apnea of infancy

 

 

ANS:  B

Plagiocephaly is a misshapen head caused by the prolonged pressure on one side of the skull. If that side becomes misshapen, facial asymmetry may result. SIDS has decreased by more than 40% with the introduction of the Back to Sleep campaign. Apnea of infancy and failure to thrive are unrelated to the Back to Sleep campaign.

 

DIF:    Cognitive Level: Understanding     REF:   p. 478

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is interviewing the parents of a 4-month-old boy brought to the hospital emergency department. The infant is dead, and no attempt at resuscitation is made. The parents state that the baby was found in his crib with a blanket over his head, lying face down in bloody fluid from his nose and mouth. The nurse might initially suspect his death was caused by what?
a. Suffocation
b. Child abuse
c. Infantile apnea
d. Sudden infant death syndrome (SIDS)

 

 

ANS:  D

The description of how the child was found in the crib is suggestive of SIDS. The nurse is careful to tell the parents that a diagnosis cannot be confirmed until an autopsy is performed.

 

DIF:    Cognitive Level: Applying              REF:   p. 473

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. What is an important nursing responsibility when dealing with a family experiencing the loss of an infant from sudden infant death syndrome (SIDS)?
a. Discourage the parents from making a last visit with the infant.
b. Make a follow-up home visit to the parents as soon as possible after the child’s death.
c. Explain how SIDS could have been predicted and prevented.
d. Interview the parents in depth concerning the circumstances surrounding the child’s death.

 

 

ANS:  B

A competent, qualified professional should visit the family at home as soon as possible after the death. Printed information about SIDS should be provided to the family. Parents should be allowed and encouraged to make a last visit with their child. SIDS cannot always be prevented or predicted, but parents can take steps to reduce the risk (e.g., supine sleeping, removing blankets and pillows from the crib, and not smoking). Discussions about the cause only increase parental guilt. The parents should be asked only factual questions to determine the cause of death.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 477

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Psychosocial Integrity

 

  1. What is an appropriate action when an infant becomes apneic?
a. Shake vigorously.
b. Roll the infant’s head to the side.
c. Gently stimulate the trunk by patting or rubbing.
d. Hold the infant by the feet upside down with the head supported.

 

 

ANS:  C

If an infant is apneic, the infant’s trunk should be gently stimulated by patting or rubbing. If the infant is prone, turn onto the back. Vigorous shaking, rolling of the head, and hanging the child upside down can cause injury and should not be done.

 

DIF:    Cognitive Level: Understanding     REF:   p. 481

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A parent brings a 12-month-old infant into the emergency department and tells the nurse that the infant is allergic to peanuts and was accidentally given a cookie with peanuts in it. The infant is dyspneic, wheezing, and cyanotic. The health care provider has prescribed a dose of epinephrine to be administered. The infant weighs 24 lb. How many milligrams of epinephrine should be administered?
a. 0.11 to 0.33 mg
b. 0.011 to 0.3 mg
c. 1.1 to 3.3 mg
d. 11 to 33 mg

 

 

ANS:  B

The correct dose of epinephrine to use in the emergency management of an anaphylactic reaction is 0.001 mg/kg up to a maximum of 0.3 mg, giving a range of 0.011 to 0.3 mg using a weight of 11 kg (24 lb).

 

DIF:    Cognitive Level: Applying              REF:   p. 459

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is teaching a parent with a 2-month-old infant who has been diagnosed with colic about ways to relieve colic. Which statement by the parent indicates the need for additional teaching?
a. “I should let my infant cry for at least 30 minutes before I respond.”
b. “I will swaddle my infant tightly with a soft blanket.”
c. “I should massage my infant’s abdomen whenever possible.”
d. “I will place my infant in an upright seat after feeding.”

 

 

ANS:  A

Because the infant has been diagnosed with colic, the parent should respond to the infant immediately or any type of interventions to relieve colic may not be effective. Also, the infant may develop a mistrust of the world if his or her needs are not met. The parent should swaddle the baby tightly with a soft blanket, massage the baby’s abdomen, and place the infant in an upright seat after a feeding to help relieve colic.

 

DIF:    Cognitive Level: Applying              REF:   p. 471

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity

 

  1. A new parent relates to the nurse that the family has many known food allergies. Which is considered a primary strategy for feeding the infant with many family food allergies?
a. Using soy formula for feeding
b. Maternal avoidance of cow’s milk protein
c. Exclusive breastfeeding for 4 to 6 months
d. Delaying the introduction of highly allergenic foods past 6 months

 

 

ANS:  C

Exclusive breastfeeding for 4 to 6 months is now considered a primary strategy for avoiding atopy in families with known food allergies; however, there is no evidence that maternal avoidance (during pregnancy or lactation) of cow’s milk protein or other dietary products known to cause food allergy will prevent food allergy in children. Researchers indicate that delaying the introduction of highly allergenic foods past 4 to 6 months of age may not be as protective for food allergy as previously believed. Likewise, studies have shown that soy formula does not prevent allergic disease in infants.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 460            TOP:   Nursing Process: Planning

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. A bottle-fed infant has been diagnosed with cow’s milk allergy. Which formula should the nurse expect to be prescribed for the infant?
a. Similac
b. Pregestimil
c. Enfamil with iron
d. Gerber Good Start

 

 

ANS:  B

For infants with cow’s milk allergy, the formula will be changed to a casein hydrolysate milk formula (Pregestimil, Nutramigen, or Alimentum) in which the protein has been broken down into its amino acids through enzymatic hydrolysis. Similac, Enfamil with iron, and Gerber Good Start are cow’s milk–based formulas.

 

DIF:    Cognitive Level: Applying              REF:   p. 461            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is collecting a stool sample from an infant with lactose intolerance. Which fecal pH should the nurse expect as the result?
a. 5.5
b. 7.0
c. 7.5
d. 8

 

 

ANS:  A

An acidic pH (5–5.5) indicates malabsorption, which occurs with lactose intolerance. The normal pH of the stool is 7.0 to 7.5. A finding of 8 would be alkaline.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 462

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. An infant has been diagnosed with failure to thrive (FTT) classified according to the pathophysiology of inadequate caloric intake. The nurse understands that the reason for the FTT is most likely related to what?
a. Cow’s milk allergy
b. Congenital heart disease
c. Metabolic storage disease
d. Incorrect formula preparation

 

 

ANS:  D

FTT classified according to the pathophysiology of inadequate caloric intake is related to incorrect formula preparation, neglect, food fads, excessive juice poverty, breastfeeding problems, behavioral problems affecting eating, parental restriction of caloric intake, or central nervous system problems affecting intake consumption. Cow’s milk allergy would be related to the pathophysiology of inadequate absorption, congenital heart disease would be related to the pathophysiology of increased metabolism, and metabolic storage disease is related to defective utilization.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 463

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. An infant has been diagnosed with failure to thrive (FTT) classified according to the pathophysiology of defective utilization. The nurse understands that the reason for the FTT is most likely related to what?
a. Cystic fibrosis
b. Hyperthyroidism
c. Congenital infection
d. Breastfeeding problems

 

 

ANS:  C

FTT classified according to the pathophysiology of defective utilization is related to a genetic anomaly, congenital infection of metabolic storage disease. Cystic fibrosis would be related to the pathophysiology of inadequate absorption, hyperthyroidism would be related to the pathophysiology of increased metabolism, and breastfeeding problems are related to inadequate caloric intake.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 463

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is teaching parents guidelines for feeding their 8-month-old infant with failure to thrive (FTT). Which statement by the parents indicates a need for further teaching?
a. “We will continue to use the 24-kcal/oz formula.”
b. “We will be sure to follow the formula preparation instructions.”
c. “We will be sure to give our infant at least 8 oz of juice every day.”
d. “We will be sure to feed our infant according to the written schedule.”

 

 

ANS:  C

Juice intake in infants with FTT should be withheld until adequate weight gain has been achieved with appropriate milk sources; thereafter, no more than 4/oz day of juice should be given. Further teaching is needed if the parents indicate 8 oz of juice is allowed. For infants with FTT, 24-kcal/oz formulas may be provided to increase caloric intake. Because maladaptive feeding practices often contribute to growth failure, parents should follow specific step-by-step directions for formula preparation, as well as a written schedule of feeding times. Statements by the parents indicating they will use a 24-kcal/oz formula, follow directions for formula preparation, and feed their infant on schedule are accurate statements.

 

DIF:    Cognitive Level: Applying              REF:   p. 463

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is teaching parents about caring for their infant with seborrheic dermatitis (cradle cap). Which statement by the parents indicates understanding of the teaching?
a. “We will rinse off the shampoo quickly and dry the scalp thoroughly.”
b. “We will shampoo the hair every other day with antiseborrheic shampoo.”
c. “We will be sure to shampoo the hair without removing any of the crusts.”
d. “We will use a fine-tooth comb to help remove the loosened crusts from the strands of hair.”

 

 

ANS:  D

A fine-tooth comb or a soft facial brush helps remove the loosened crusts from the strands of hair after shampooing. This is an accurate statement. Shampoo should applied to the scalp and allowed to remain on the scalp until the crusts soften. Shampoo should not be rinsed off quickly. The crusts should be removed, and shampooing with antiseborrheic shampoo should be done daily, not every other day.

 

DIF:    Cognitive Level: Applying              REF:   p. 467

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is administering an oral antihistamine at bedtime to a child with atopic dermatitis (eczema). Which antihistamine should the nurse expect to be prescribed at bedtime?
a. Cetirizine (Zyrtec)
b. Loratadine (Claritin)
c. Fexofenadine (Allegra)
d. Diphenhydramine (Benadryl)

 

 

ANS:  D

Oral antihistamine drugs such as hydroxyzine or diphenhydramine usually relieve moderate or severe pruritus. Nonsedating antihistamines such as cetirizine (Zyrtec), loratadine (Claritin), or fexofenadine (Allegra) may be preferred for daytime pruritus relief. Because pruritus increases at night, a mildly sedating antihistamine such as Benadryl is prescribed.

 

DIF:    Cognitive Level: Applying              REF:   p. 469

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

MULTIPLE RESPONSE

 

  1. The nurse is planning care for an infant with eczema. Which interventions should the nurse include in the care plan? (Select all that apply.)
a. Avoid giving the infant a bubble bath.
b. Avoid the use of a humidifier in the infant’s room.
c. Avoid overdressing the infant.
d. Avoid the use of topical steroids on the infant’s skin.
e. Avoid wet compresses on the infant’s most affected areas.

 

 

ANS:  A, C

Guidelines for care of an infant with eczema include avoiding a bubble bath and harsh soaps and avoiding overdressing the infant to prevent perspiration, which can cause a flare-up. The care plan should include using a humidifier in the infant’s room, topical steroids, and wet compresses on the most affected areas.

 

DIF:    Cognitive Level: Applying              REF:   p. 469            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. The community health nurse is reviewing risk factors for vitamin D deficiency. Which children are at high risk for vitamin D deficiency? (Select all that apply.)
a. Children with fair pigmentation
b. Children who are overweight or obese
c. Children who are exclusively bottle fed
d. Children with diets low in sources of vitamin D
e. Children of families who use milk products not supplemented with vitamin D

 

 

ANS:  B, D, E

Populations at risk for vitamin D deficiency include overweight or obese children, children with diets low in sources of vitamin D, and children of families who use milk products not supplemented with vitamin D. Children with dark, not fair, pigmentation and children who are exclusively breast fed, not bottle fed, are also at risk.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 453

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse has administered a dose of epinephrine to a 12-month-old infant. For which adverse reactions of epinephrine should the nurse monitor? (Select all that apply.)
a. Nausea
b. Tremors
c. Irritability
d. Bradycardia
e. Hypotension

 

 

ANS:  A, B, C

Epinephrine increases activation of the sympathetic nervous system. Adverse effects include nausea, tremors, and irritability. Tachycardia would occur, not bradycardia, and hypertension, not hypotension, would occur.

 

DIF:    Cognitive Level: Applying              REF:   p. 459

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. A 12-month-old infant has been diagnosed with failure to thrive (FTT). Which assessment findings does the nurse expect to be documented with this infant? (Select all that apply.)
a. Fear of strangers
b. Minimal smiling
c. Avoidance of eye contact
d. Meeting developmental milestones
e. Wide-eyed gaze and continual scan of the environment

 

 

ANS:  B, C, E

Signs and symptoms of FTT include minimal smiling, avoidance of eye contact, and a wide-eyed gaze and continual scan of the environment (“radar gaze”). There is no fear of strangers, and there are developmental delays, including social, motor, adaptive, and language.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 463

TOP:   Integrated Process: Communication and Documentation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is preparing to feed a 10-month-old child diagnosed with failure to thrive (FTT). Which actions should the nurse plan to implement? (Select all that apply.)
a. Be persistent.
b. Introduce new foods slowly.
c. Provide a stimulating atmosphere.
d. Maintain a calm, even temperament.
e. Feed the infant only when signs of hunger are exhibited.

 

 

ANS:  A, B, D

Feeding strategies for children with FTT should include persistence; introducing new foods slowly; and maintaining a calm, even temperament. The environment should be unstimulating, and a structured routine should be developed with regard to feeding, not just when the infant shows signs of hunger.

 

DIF:    Cognitive Level: Applying              REF:   p. 463

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is teaching parents about foods that are hyperallergenic. Which foods should the nurse include? (Select all that apply.)
a. Peanuts
b. Bananas
c. Potatoes
d. Egg noodles
e. Tomato juice

 

 

ANS:  A, D, E

Hyperallergenic foods include peanuts, egg noodles, and tomato juice. Bananas and potatoes are not hyperallergenic.

 

DIF:    Cognitive Level: Applying              REF:   p. 470

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is teaching parents about potential causes of colic in infancy. Which should the nurse include in the teaching session? (Select all that apply.)
a. Overeating
b. Understimulation
c. Frequent burping
d. Parental smoking
e. Swallowing excessive air

 

 

ANS:  A, D, E

Potential causes of colic include too rapid feeding, overeating, swallowing excessive air, improper feeding technique (especially in positioning and burping), emotional stress or tension between the parent and child, parental smoking, and overstimulation.

 

DIF:    Cognitive Level: Applying              REF:   p. 470

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What are risk factors for sudden infant death syndrome? (Select all that apply.)
a. Postterm
b. Female gender
c. Low Apgar scores
d. Recent viral illness
e. Native American infants

 

 

ANS:  C, D, E

Infant risk factors for sudden infant death syndrome include those with low Apgar scores and recent viral illness and Native American infants. Preterm, not postterm, birth and male, not female, gender are other risk factors.

 

DIF:    Cognitive Level: Understanding     REF:   p. 475

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is teaching parents strategies to manage their child’s refusal to go to sleep. Which should the nurse include in the teaching session? (Select all that apply.)
a. Keep bedtime early.
b. Enforce consistent limits.
c. Use a reward system with the child.
d. Have a consistent before bedtime routine.

 

 

ANS:  B, C, D

Strategies to manage a child’s refusal to go to sleep include enforcement of consistent limits, using a reward system, and having a consistent before bedtime routine. An evaluation of whether the hour of sleep is too early should be considered because an early bedtime could cause the child to resist sleep if not tired.

 

DIF:    Cognitive Level: Applying              REF:   p. 472

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

 

COMPLETION

 

  1. A health care provider prescribes vitamin D supplements, 300 IU orally, daily. The medication label states: “Vitamin D 1000 IU/10 ml.” The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer in a whole number.

________________

 

ANS:

3

 

Follow the formula for dosage calculation.

Desired

———– ´ Volume = ml per dose

Available

 

300 IU

———– ´ 10 ml = 3 ml

1000 IU

 

DIF:    Cognitive Level: Applying              REF:   p. 453

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A health care provider prescribes iron supplements (Fer-In-Sol), 1 mg/kg/day orally (PO). The infant weighs 5 kg. The medication label states: “Fer-In-Sol 25 mg/1 ml.” The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer to one decimal place.

________________

 

ANS:

0.2

 

Follow the formula for dosage calculation.

Multiply 1 mg ´ 5 kg to get the dose = 5 mg

 

Desired

———– ´ Volume = ml per dose

Available

 

5 mg

———– ´ 1 ml = 0.2 ml

25 mg

 

DIF:    Cognitive Level: Applying              REF:   p. 454

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A health care provider prescribes adrenaline (epinephrine), intramuscularly (IM) 0.15 mg, times one, stat. The medication label states: “Epinephrine 1:1000 1 mg/1 ml.” The nurse prepares to administer the stat dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer using two decimal places.

________________

 

ANS:

0.15

 

Follow the formula for dosage calculation.

Desired

———– ´ Volume = ml per dose

Available

 

0.15 mg

———– ´ 1 ml = 0.15 ml

1 mg

 

DIF:    Cognitive Level: Applying              REF:   p. 459

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

MATCHING

 

Match the following terms related to food sensitivities to the accurate descriptions.

a. Food allergy
b. Food allergen
c. Food intolerance
d. Sensitization
e. Atopy

 

 

  1. A food elicits a reproducible adverse reaction but does not have an established immunologic mechanism

 

  1. An adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food

 

  1. Specific components of food or ingredients in food that are recognized by allergen-specific immune cells eliciting an immune reaction

 

  1. Allergy with a hereditary tendency

 

  1. Initial exposure to an allergen resulting in an immune response; subsequent exposure induces a much stronger response

 

  1. ANS:  C                    DIF:    Cognitive Level: Understanding     REF:   p. 457

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. ANS:  A                    DIF:    Cognitive Level: Understanding     REF:   p. 457

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. ANS:  B                    DIF:    Cognitive Level: Understanding     REF:   p. 457

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. ANS:  E                    DIF:    Cognitive Level: Understanding     REF:   p. 458

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. ANS:  D                    DIF:    Cognitive Level: Understanding     REF:   p. 458

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance