Question 1 See full question
Parents bring their infant to the clinic, seeking treatment for vomiting and diarrhea that
has lasted for 2 days. On assessment, the nurse detects dry mucous membranes and
lethargy. What other finding suggests a fluid volume deficit?
You Selected:
A sunken fontanel
Correct response:
A sunken fontanel
Explanation:
In an infant, signs of fluid volume deficit (dehydration) include sunken fontanels,
increased pulse rate, and decreased blood pressure. They occur when the body can no
longer maintain sufficient intravascular fluid volume. When this happens, the kidneys
conserve water to minimize fluid loss, which results in concentrated urine with a high
specific gravity.
Question 2 See full question
A mother of a hospitalized infant appears anxious and displays anger with the staff.
Which response is most appropriate?
You Selected:
"You seem upset. Having your child hospitalized must be difficult."
Correct response:
"You seem upset. Having your child hospitalized must be difficult."
Explanation:
Acknowledging the mother's feelings and recognizing that it's difficult to cope with a
hospitalized child allows the mother to express her feelings. Telling the mother that
other staff members don't want to talk to her isn't therapeutic. Asking her to explain her
behavior places the mother on the defensive and also isn't therapeutic.
Question 3 See full question
An infant who has been in foster care since birth requires a blood transfusion. Who is
authorized to give written, informed consent for the procedure?
You Selected:
The foster mother
,Correct response:
The foster mother
Explanation:
When children are minors and aren't emancipated, their parents or designated legal
guardians are responsible for providing consent for medical procedures. Therefore, the
foster mother is authorized to give consent for the blood transfusion. The social worker,
the nurse, and the nurse manager have no legal rights to give consent in this scenario.
Question 4 See full question
The most appropriate toys to give to a 5-month-old infant are:
You Selected:
soft, washable toys.
Correct response:
soft, washable toys.
Explanation:
Soft, washable toys are appropriate for infants, who tend to place everything in their
mouths. These toys are not harmful. Plastic toys cannot be manipulated by a child of
this age, and the child would put the car in the mouth, which may not be safe due to
small parts that may be swallowed or aspirated. Games and puzzles are too advanced
for a 5-month-old, and the child could put the pieces in the mouth and swallow them.
Some stuffed animals have eyes that can be swallowed or aspirated.
Question 5 See full question
Which serum electrolytes findings should the nurse expect to find in an infant with
persistent vomiting?
You Selected:
K+, 3.2; Cl-, 92; Na+, 120
Correct response:
K+, 3.2; Cl-, 92; Na+, 120
Explanation:
Chloride and sodium function together to maintain fluid and electrolyte balance. With
vomiting, sodium chloride and water are lost in gastric fluid. As dehydration occurs,
potassium moves into the extracellular fluid. For these reasons, persistent vomiting can
lead to hypokalemia, hypochloremia, and hyponatremia.
,The normal potassium level is 3.5 to 5.5, the normal chloride level is 98 to 106, and the
normal sodium level is 135 to 145. The values of 3.2, 92, and 120, respectively, are
consistent with persistent vomiting.
Each of the other options includes at least two serum electrolyte levels that are normal
or high. These are not consistent with persistent vomiting.
Question 1 See full question
The physician suspects tracheoesophageal fistula in a 1-day-old neonate. Which
nursing intervention is most appropriate for this child?
You Selected:
Elevating the neonate's head and giving nothing by mouth
Correct response:
Elevating the neonate's head and giving nothing by mouth
Explanation:
Because of the risk of aspiration, a neonate with a known or suspected
tracheoesophageal fistula should be kept with the head elevated at all times and should
receive nothing by mouth (NPO). The nurse should suction the neonate regularly to
maintain a patent airway and prevent pooling of secretions. Elevating the neonate's
head after feedings or giving glucose water are inappropriate because the neonate must
remain on NPO status.
Question 2 See full question
An infant is hospitalized for treatment of inorganic failure to thrive. Which nursing action
is most appropriate for this child?
You Selected:
Maintaining a consistent, structured environment
Correct response:
Maintaining a consistent, structured environment
Explanation:
The nurse caring for an infant with inorganic failure to thrive should strive to maintain a
consistent, structured environment because it reinforces a caring feeding environment.
, Encouraging the infant to hold a bottle would reinforce an uncaring feeding
environment. The infant should receive social stimulation rather than be confined to bed
rest. The number of caregivers should be minimized to promote consistency of care.
Question 3 See full question
When teaching a group of parents about the potential for febrile seizures in children,
which fact should the nurse include?
You Selected:
The seizures occur as the fever rises.
Correct response:
The seizures occur as the fever rises.
Explanation:
Febrile seizures commonly occur as the fever rises. The exact cause of febrile
convulsions is not known. Infants and young toddlers are the age-groups primarily
affected. Febrile seizures typically do not follow immunization administration.
Question 4 See full question
An infant is being treated at home for bronchiolitis. What should the nurse teach the
parent about home care? Select all that apply.
You Selected:
watching for difficulty breathing
offering small amounts of fluids frequently
Correct response:
offering small amounts of fluids frequently
watching for difficulty breathing
Explanation:
An infant with bronchiolitis will have increased respirations and will tire more quickly, so
it is best and easiest for the infant to take fluids more often in smaller amounts. The
parents also would be instructed to watch for signs of increased difficulty breathing,
which signal possible complications. Healthy infants and even those with bronchiolitis
should sleep in the supine position. Calling the clinic for an episode of vomiting would
not be necessary. However, the parents would be instructed to call if the infant cannot
keep down any fluids for a period of more than 4 hours. Parents would not need to
Parents bring their infant to the clinic, seeking treatment for vomiting and diarrhea that
has lasted for 2 days. On assessment, the nurse detects dry mucous membranes and
lethargy. What other finding suggests a fluid volume deficit?
You Selected:
A sunken fontanel
Correct response:
A sunken fontanel
Explanation:
In an infant, signs of fluid volume deficit (dehydration) include sunken fontanels,
increased pulse rate, and decreased blood pressure. They occur when the body can no
longer maintain sufficient intravascular fluid volume. When this happens, the kidneys
conserve water to minimize fluid loss, which results in concentrated urine with a high
specific gravity.
Question 2 See full question
A mother of a hospitalized infant appears anxious and displays anger with the staff.
Which response is most appropriate?
You Selected:
"You seem upset. Having your child hospitalized must be difficult."
Correct response:
"You seem upset. Having your child hospitalized must be difficult."
Explanation:
Acknowledging the mother's feelings and recognizing that it's difficult to cope with a
hospitalized child allows the mother to express her feelings. Telling the mother that
other staff members don't want to talk to her isn't therapeutic. Asking her to explain her
behavior places the mother on the defensive and also isn't therapeutic.
Question 3 See full question
An infant who has been in foster care since birth requires a blood transfusion. Who is
authorized to give written, informed consent for the procedure?
You Selected:
The foster mother
,Correct response:
The foster mother
Explanation:
When children are minors and aren't emancipated, their parents or designated legal
guardians are responsible for providing consent for medical procedures. Therefore, the
foster mother is authorized to give consent for the blood transfusion. The social worker,
the nurse, and the nurse manager have no legal rights to give consent in this scenario.
Question 4 See full question
The most appropriate toys to give to a 5-month-old infant are:
You Selected:
soft, washable toys.
Correct response:
soft, washable toys.
Explanation:
Soft, washable toys are appropriate for infants, who tend to place everything in their
mouths. These toys are not harmful. Plastic toys cannot be manipulated by a child of
this age, and the child would put the car in the mouth, which may not be safe due to
small parts that may be swallowed or aspirated. Games and puzzles are too advanced
for a 5-month-old, and the child could put the pieces in the mouth and swallow them.
Some stuffed animals have eyes that can be swallowed or aspirated.
Question 5 See full question
Which serum electrolytes findings should the nurse expect to find in an infant with
persistent vomiting?
You Selected:
K+, 3.2; Cl-, 92; Na+, 120
Correct response:
K+, 3.2; Cl-, 92; Na+, 120
Explanation:
Chloride and sodium function together to maintain fluid and electrolyte balance. With
vomiting, sodium chloride and water are lost in gastric fluid. As dehydration occurs,
potassium moves into the extracellular fluid. For these reasons, persistent vomiting can
lead to hypokalemia, hypochloremia, and hyponatremia.
,The normal potassium level is 3.5 to 5.5, the normal chloride level is 98 to 106, and the
normal sodium level is 135 to 145. The values of 3.2, 92, and 120, respectively, are
consistent with persistent vomiting.
Each of the other options includes at least two serum electrolyte levels that are normal
or high. These are not consistent with persistent vomiting.
Question 1 See full question
The physician suspects tracheoesophageal fistula in a 1-day-old neonate. Which
nursing intervention is most appropriate for this child?
You Selected:
Elevating the neonate's head and giving nothing by mouth
Correct response:
Elevating the neonate's head and giving nothing by mouth
Explanation:
Because of the risk of aspiration, a neonate with a known or suspected
tracheoesophageal fistula should be kept with the head elevated at all times and should
receive nothing by mouth (NPO). The nurse should suction the neonate regularly to
maintain a patent airway and prevent pooling of secretions. Elevating the neonate's
head after feedings or giving glucose water are inappropriate because the neonate must
remain on NPO status.
Question 2 See full question
An infant is hospitalized for treatment of inorganic failure to thrive. Which nursing action
is most appropriate for this child?
You Selected:
Maintaining a consistent, structured environment
Correct response:
Maintaining a consistent, structured environment
Explanation:
The nurse caring for an infant with inorganic failure to thrive should strive to maintain a
consistent, structured environment because it reinforces a caring feeding environment.
, Encouraging the infant to hold a bottle would reinforce an uncaring feeding
environment. The infant should receive social stimulation rather than be confined to bed
rest. The number of caregivers should be minimized to promote consistency of care.
Question 3 See full question
When teaching a group of parents about the potential for febrile seizures in children,
which fact should the nurse include?
You Selected:
The seizures occur as the fever rises.
Correct response:
The seizures occur as the fever rises.
Explanation:
Febrile seizures commonly occur as the fever rises. The exact cause of febrile
convulsions is not known. Infants and young toddlers are the age-groups primarily
affected. Febrile seizures typically do not follow immunization administration.
Question 4 See full question
An infant is being treated at home for bronchiolitis. What should the nurse teach the
parent about home care? Select all that apply.
You Selected:
watching for difficulty breathing
offering small amounts of fluids frequently
Correct response:
offering small amounts of fluids frequently
watching for difficulty breathing
Explanation:
An infant with bronchiolitis will have increased respirations and will tire more quickly, so
it is best and easiest for the infant to take fluids more often in smaller amounts. The
parents also would be instructed to watch for signs of increased difficulty breathing,
which signal possible complications. Healthy infants and even those with bronchiolitis
should sleep in the supine position. Calling the clinic for an episode of vomiting would
not be necessary. However, the parents would be instructed to call if the infant cannot
keep down any fluids for a period of more than 4 hours. Parents would not need to
