A parent of a 6-month-old infant asks the nurse which foods should be introduced first. What is
the best response by the nurse?
Baby cereals
Soft-boiled eggs
Fruits and puddings
Meats and vegetables
A 6-week-old infant has surgery for hypertrophic pyloric stenosis (HPS). When encouraged to
participate in caring for her infant, the mother readily assists with all aspects of care but is
reluctant to resume feeding her baby. The mother states, "I just can't stand to watch him choke
and cough." What is the most likely reason that the mother does not feed her infant?
Afraid that her baby's vomiting will resume
Unaware that she is allowed to feed her baby
Not sure how to feed her baby with a special nipple
Uncertain whether her baby will tolerate the thickened formula
A 3-month-old infant hospitalized with severe diarrhea has excoriated skin in the diaper area.
The parents become concerned when they discover that the nurse has left the infant without a
diaper. What is the nurse's explanation for this action?
Exposing the excoriated areas helps reduce the fever.
Cleansing of the skin followed by air-drying reduces excoriation.
Air-drying the perineal area prevents the diaper from sticking to the skin.
Leaving the area exposed allows observation of when the infant passes stool.
A 4-day-old infant is admitted to the pediatric unit with a cleft lip and palate. Surgery to repair
the lip is scheduled for later in the week. Which assessment finding requires notification of the
surgeon and will probably result in cancellation of the surgery?
Hypotonia
Oral candidiasis
Facial paralysis
Cephalohematoma
A nurse is performing a respiratory assessment of an 8-month-old child with the diagnosis of
viral pneumonia. The nurse identifies bronchial breath sounds over areas of consolidation, mild
substernal retractions, profuse mucus production, pallor, and a temperature of 102° F (38.9° C).
What is the prioritynursing action?
Suctioning the nasopharynx so a patent airway can be maintained
Starting an intravenous infusion to provide necessary fluids and electrolytes
Calling the respiratory therapist to start preparations for oxygen administration
Notifying the practitioner of the fever so a prescription for an antipyretic can be issued
A nurse is assessing the oral cavity of a 6-month-old infant. The parent asks which teeth will
erupt first. What is the nurse's response?
, Incisors
Canines
Upper molars
Lower molars
A nurse who is assigned to care for a 6-month-old infant with diarrhea is reviewing the infant's
medical history, assessment findings, laboratory reports, and practitioner prescriptions. The
infant weighs 15½ lb (7 kg). The healthcare provider has written a prescription for potassium
chloride to be added to the IV fluids. What assessment finding signals the nurse to question this
prescription?
Incessant crying
Inadequate tissue turgor
Urinary output of 4 mL over 2 hours
Oral fluid intake of 12 mL over 8 hours
When picked up by a parent or the nurse, an 8-month-old infant screams and seems to be in pain.
After observing this behavior, what should the nurse discuss with the parent?
Accidents and the importance of their prevention
Limiting playtime with other children in the family
Any other behaviors that the parent might have noticed
Food and specific vitamins that should be given to infants
A cardiac catheterization is performed on an infant. After the procedure, the leg used for the
catheter insertion site becomes mottled. What is the best action by the nurse?
Elevating the leg
Covering the leg with a blanket
Checking the pulse in the extremity
Notifying the primary healthcare provider
A 3-month-old infant with chronic constipation has a tentative diagnosis of Hirschsprung
disease. What definitive diagnostic test does the nurse expect to prepare the infant for?
Sweat test
Guthrie test
Rectal biopsy
Blood glucose level
The nurse is assigned a group of pediatric clients. After receiving shift report, which client
should the nurse assess first?
A 6-month-old with a croupy cough and inspiratory stridor with exertion
A 2-year-old with asthma who required a PRN albuterol treatment 2 hours ago
A 3-year-old with cystic fibrosis and pneumonia who required 22% oxygen all night
A 20-month-old with bronchiolitis and bilateral crackles who is receiving 23% oxygen
, The parents of a 6-month-old infant ask the nurse about the best toy to buy for their baby. What
type of toy should the nurse suggest?
Push-pull
Wooden blocks
Shape-matching
Soft stuffed animals
The parent of a 10-month-old infant with otitis media tells the nurse in the pediatric clinic that
this is the baby's third episode in 3 months. The infant is tugging at the ear but is not acutely ill.
What factor should the nurse consider before responding?
Analgesics are contraindicated.
Oral antibiotics will be prescribed.
The labyrinth and cochlea are inflamed.
The eustachian tube is short and horizontal.
The parents of an infant who is to undergo insertion of a right ventriculoperitoneal shunt for
hydrocephalus are taught about postoperative positioning that helps prevent pressure on the valve
site. What statement indicates that they understand the teaching?
"We'll place her in the position that seems comfortable."
"The flat left side-lying position is the safest position for our baby."
"We should place her on her back with a small support under the neck."
"The right side-lying position with the head supported is the best position."
A home care nurse is visiting a family for the first time. The family’s 4-week-old infant
underwent surgery for exstrophy of the bladder and creation of an ileal conduit soon after birth.
When the nurse arrives, the mother appears tired and the baby is crying. After an introduction,
which is the most appropriate statement by the nurse?
"Tell me about your daily routine."
"You look tired. Is everything all right?"
"When was the last time the baby had a bottle?"
"Oh, it looks like you two are having a bad day."
A nurse in the emergency department is assessing a 10-month-old infant who was injured in an
automobile collision. The infant, who is quiet but does not appear lethargic, has a large
hematoma on the left temporal area. What sign of neurologic involvement is the most critical to
identify?
Babinski reflex
Persistent vomiting
Heart rate of 110 beats/min
Temperature of 99.6° F (37.6° C)
A nurse in the pediatric clinic is assessing an infant who had a revision of a ventriculoperitoneal
shunt. What clinical finding alerts the nurse that intracranial pressure has increased?
the best response by the nurse?
Baby cereals
Soft-boiled eggs
Fruits and puddings
Meats and vegetables
A 6-week-old infant has surgery for hypertrophic pyloric stenosis (HPS). When encouraged to
participate in caring for her infant, the mother readily assists with all aspects of care but is
reluctant to resume feeding her baby. The mother states, "I just can't stand to watch him choke
and cough." What is the most likely reason that the mother does not feed her infant?
Afraid that her baby's vomiting will resume
Unaware that she is allowed to feed her baby
Not sure how to feed her baby with a special nipple
Uncertain whether her baby will tolerate the thickened formula
A 3-month-old infant hospitalized with severe diarrhea has excoriated skin in the diaper area.
The parents become concerned when they discover that the nurse has left the infant without a
diaper. What is the nurse's explanation for this action?
Exposing the excoriated areas helps reduce the fever.
Cleansing of the skin followed by air-drying reduces excoriation.
Air-drying the perineal area prevents the diaper from sticking to the skin.
Leaving the area exposed allows observation of when the infant passes stool.
A 4-day-old infant is admitted to the pediatric unit with a cleft lip and palate. Surgery to repair
the lip is scheduled for later in the week. Which assessment finding requires notification of the
surgeon and will probably result in cancellation of the surgery?
Hypotonia
Oral candidiasis
Facial paralysis
Cephalohematoma
A nurse is performing a respiratory assessment of an 8-month-old child with the diagnosis of
viral pneumonia. The nurse identifies bronchial breath sounds over areas of consolidation, mild
substernal retractions, profuse mucus production, pallor, and a temperature of 102° F (38.9° C).
What is the prioritynursing action?
Suctioning the nasopharynx so a patent airway can be maintained
Starting an intravenous infusion to provide necessary fluids and electrolytes
Calling the respiratory therapist to start preparations for oxygen administration
Notifying the practitioner of the fever so a prescription for an antipyretic can be issued
A nurse is assessing the oral cavity of a 6-month-old infant. The parent asks which teeth will
erupt first. What is the nurse's response?
, Incisors
Canines
Upper molars
Lower molars
A nurse who is assigned to care for a 6-month-old infant with diarrhea is reviewing the infant's
medical history, assessment findings, laboratory reports, and practitioner prescriptions. The
infant weighs 15½ lb (7 kg). The healthcare provider has written a prescription for potassium
chloride to be added to the IV fluids. What assessment finding signals the nurse to question this
prescription?
Incessant crying
Inadequate tissue turgor
Urinary output of 4 mL over 2 hours
Oral fluid intake of 12 mL over 8 hours
When picked up by a parent or the nurse, an 8-month-old infant screams and seems to be in pain.
After observing this behavior, what should the nurse discuss with the parent?
Accidents and the importance of their prevention
Limiting playtime with other children in the family
Any other behaviors that the parent might have noticed
Food and specific vitamins that should be given to infants
A cardiac catheterization is performed on an infant. After the procedure, the leg used for the
catheter insertion site becomes mottled. What is the best action by the nurse?
Elevating the leg
Covering the leg with a blanket
Checking the pulse in the extremity
Notifying the primary healthcare provider
A 3-month-old infant with chronic constipation has a tentative diagnosis of Hirschsprung
disease. What definitive diagnostic test does the nurse expect to prepare the infant for?
Sweat test
Guthrie test
Rectal biopsy
Blood glucose level
The nurse is assigned a group of pediatric clients. After receiving shift report, which client
should the nurse assess first?
A 6-month-old with a croupy cough and inspiratory stridor with exertion
A 2-year-old with asthma who required a PRN albuterol treatment 2 hours ago
A 3-year-old with cystic fibrosis and pneumonia who required 22% oxygen all night
A 20-month-old with bronchiolitis and bilateral crackles who is receiving 23% oxygen
, The parents of a 6-month-old infant ask the nurse about the best toy to buy for their baby. What
type of toy should the nurse suggest?
Push-pull
Wooden blocks
Shape-matching
Soft stuffed animals
The parent of a 10-month-old infant with otitis media tells the nurse in the pediatric clinic that
this is the baby's third episode in 3 months. The infant is tugging at the ear but is not acutely ill.
What factor should the nurse consider before responding?
Analgesics are contraindicated.
Oral antibiotics will be prescribed.
The labyrinth and cochlea are inflamed.
The eustachian tube is short and horizontal.
The parents of an infant who is to undergo insertion of a right ventriculoperitoneal shunt for
hydrocephalus are taught about postoperative positioning that helps prevent pressure on the valve
site. What statement indicates that they understand the teaching?
"We'll place her in the position that seems comfortable."
"The flat left side-lying position is the safest position for our baby."
"We should place her on her back with a small support under the neck."
"The right side-lying position with the head supported is the best position."
A home care nurse is visiting a family for the first time. The family’s 4-week-old infant
underwent surgery for exstrophy of the bladder and creation of an ileal conduit soon after birth.
When the nurse arrives, the mother appears tired and the baby is crying. After an introduction,
which is the most appropriate statement by the nurse?
"Tell me about your daily routine."
"You look tired. Is everything all right?"
"When was the last time the baby had a bottle?"
"Oh, it looks like you two are having a bad day."
A nurse in the emergency department is assessing a 10-month-old infant who was injured in an
automobile collision. The infant, who is quiet but does not appear lethargic, has a large
hematoma on the left temporal area. What sign of neurologic involvement is the most critical to
identify?
Babinski reflex
Persistent vomiting
Heart rate of 110 beats/min
Temperature of 99.6° F (37.6° C)
A nurse in the pediatric clinic is assessing an infant who had a revision of a ventriculoperitoneal
shunt. What clinical finding alerts the nurse that intracranial pressure has increased?
