Test Bank For Pediatric Nursing The Critical Components of Nursing Care 1st Edition

Chapter 7: Newborn and Infants

Multiple Choice

1. A mother brings her 9 month infant in for a routine visit. What milestone would be appropriate for the doctor to ask if the infant is meeting?

1. Walking

2. Speaking in two word phrases

3.  Rolls back to stomach and stomach to back

4.  All of the above

ANS: 3

Feedback

1. Between 10–12 months of age, an infant can walk

2. Between 14–16 months of age, an infant can speak two word phrases

3. Between 6 and 9 months of age, an infant can roll from back to stomach and stomach to back.

4. Many infants will not be walking at this age. It is too soon for word phrases to be developed.  The child should be rolling.

KEY: Content Area: Growth and Development| Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 7 | Type: Multiple Choice

2. A 5 day old infant comes in for a newborn checkup. On assessment of the newborn, you note that the skin is jaundice in color. The anterior fontanel is slightly sunken. Per mom, the infant has only had 2 diapers today. The infant is strictly breastfed and this is mom’s first child. She states baby is having trouble latching on. A bilirubin level is sent and comes back at 18. You identify this newborn to be dehydrated and is most likely to have breast milk jaundice. Which nursing intervention(s) will be required for this baby?

1. Phototherapy

2. Providing support and education for the lactating mother

3. Strict monitoring of intake and output

4. All of the above

ANS 4

Feedback

1. Phototherapy will be required to help decrease the level of bilirubin.

2. It is important to provide the mother with support and education and offer a lactation specialist.

3. This infant is dehydrated so it will be necessary to monitor strict I & O’s.

4. Breast Milk Jaundice occurs in 1–2% of breastfed babies. At early onset there are poor feeding patterns and bilirubin levels may spike to 19. It is important to provide the mother with support and education and offer a lactation specialist. This infant is dehydrated so it will be necessary to monitor strict I & O’s.  Phototherapy will be required to help decrease the level of bilirubin.

KEY: Content Area: Hyperbilirubinemia| Integrated Processes: Nursing Process | Client Need: Physiological integrity | Cognitive Level: Application| REF: Chapter 7 | Type: Multiple Choice

3. Apgar scores measure heart rate, respiratory rate, reflex irritability, color and :

1. Rigidity

2. Muscle tone

3. Birth weight

4. Capillary refill

ANS: 2

Feedback

1. Not assessed  for the APGAR score

2. Apgar scores measure 5 areas: respiratory rate, heart rate, muscle tone, color and reflex irritability. The higher score indicates adequate adaptation. Scores are done at 1 minute and 5 minutes after birth.

3. Not assessed for the APGAR score

4. Not assessed the APGAR score

KEY: Content Area: Physiology | Integrated Processes: Nursing Process | Client Need: Psychosocial Integrity | Cognitive Level: Knowledge | REF: Chapter 7 | Type: Multiple Choice

4. A mother on the postpartum unit asked to have her infant back from the nursery so that she can breastfeed. The nurse brings the newborn to the room and hands the baby to the mother. She asks the mother to let her know how long the baby feeds.  What vital step did the nurse forget to take before giving the baby to the mother?

1. The nurse should have made sure that the baby was latching correctly

2. The nurse should have identified the baby’s ID band with the mother’s

3. The nurse should have the mother speak with a lactation consultant

4. The nurse should have asked the mother how long she planned to feed

ANS: 2

Feedback

1. It is vital that ID bands are checked with baby and mother before leaving the infant.

2. It is vital that ID bands are checked with baby and mother before leaving the infant.

3. Safety of the baby is the first priority

4. Safety of the baby is the first priority

KEY: Content Area: Safety | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Analysis | REF: Chapter 7 | Type: Multiple Choice

5. Excessive heat loss results in which of these?

1. RDS

2. Depletion of glucose levels

3. Jaundice

4. Increase in surfactant levels

ANS: 2

Feedback

1. Cold stress is excessive heat loss resulting in an increase in heart rate, respiratory rate, oxygen consumption, metabolic acidosis, depletion of glucose levels, and surfactant levels

2. Cold stress is excessive heat loss resulting in an increase in heart rate, respiratory rate, oxygen consumption, metabolic acidosis, depletion of glucose levels, and surfactant levels

3. Cold stress is excessive heat loss resulting in an increase in heart rate, respiratory rate, oxygen consumption, metabolic acidosis, depletion of glucose levels, and surfactant levels

4. Surfactant levels decrease

KEY: Content Area: Physiology| Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 7 | Type: Multiple Choice

6. A mother has just delivered her new baby a few hours ago. She asks the nurse if she can bathe the baby because he has blood on him. The best response from the nurse would be.

1. “Sure, let me get you some soap and washcloths”

2. “Why don’t you get some rest, there will be lots of time for bathing”

3. “It’s important that we not bathe the baby too soon after birth.  Let’s wait till later in the day.”

4. “Sure, but why don’t you feed the baby”

ANS: 3

Feedback

1. A nursing intervention to prevent hypothermia is to delay the first bath until the infant has regulated and stabilized core body temperature.

2. Avoids the mother’s question and an explanation should occur

3. A nursing intervention to prevent hypothermia is to delay the first bath until the infant has regulated and stabilized core body temperature.

4. Avoids the mother’s question and an explanation should occur

KEY: Content Area: Physiological| Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 7 | Type: Multiple Choice

7. A 4 week old infant is brought to the ED. Mom states that the baby hasn’t been eating well and has had decreased diapers for 2 days. The baby has been sleeping more and has been hard to wake up. On assessment, you find that the baby is difficult to arouse, is hypotonic and temperature is 35.4 rectally. What is an important lab value to check? Choose the best answer.

1. Complete metabolic panel

2. Liver panel

3. Blood glucose

4. PTT

ANS: 3

Feedback

1. Not the first choice due to the length of time to have results for  a CPM

2. The signs and symptoms do not indicate the need for a liver panel

3. Lethargy, poor feeding, hypotonic and temperature instability are all signs of hypoglycemia

4. The sign and symptoms do not indicate a need for a PTT

KEY: Content Area: Physiology| Integrated Processes: Nursing Process | Client Need: Physiology Integrity | Cognitive Level: Application | REF: Chapter 7 | Type: Multiple Choice

8. A pregnant woman with a history of a clotting disorder is required to self-administer heparin during her pregnancy. After delivery, the infant will be at greater risk for:

1. Low blood sugar

2. Decrease Vitamin K

3. Increased Vitamin K

4. High blood sugar

ANS: 2

Feedback

1. Anticoagulants do not effect blood sugar

2. An infant of a mother who is treated with anticoagulants are at risk for decreased vitamin K levels

3. Anticoagulants have the opposite effect on vitamin K

4. Anticoagulants do not effect blood sugar

KEY: Content Area: Pharmacology| Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 7 | Type: Multiple Choice

9. A part of injury prevention is making and keeping infant appointments. The required checkups and vaccinations are at:

1. 3 months, 6 months, 9 months

2. 2 months, 4 months, 6 months and 1 year

3. 2 months, 4 months, 6 month, 9 months and 1 year

4. 2 months, 4 months, 9 months and 1 year

ANS: 3

Feedback

1. It is recommended that a routine check-up with vaccinations be done at 2 months, 4 months, 6 months, 9 months and 1 year of age.

2. It is recommended that a routine check-up with vaccinations be done at 2 months, 4 months, 6 months, 9 months and 1 year of age.

3. It is recommended that a routine check-up with vaccinations be done at 2 months, 4 months, 6 months, 9 months and 1 year of age.

4. It is recommended that a routine check-up with vaccinations be done at 2 months, 4 months, 6 months, 9 months and 1 year of age.

KEY: Content Area: Growth| Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Knowledge | REF: Chapter 7 | Type: Multiple Choice

10. You are taking care of an infant who was admitted with dehydration. His weight is 6kg. You have been watching his I & O’s. What would you expect the infant’s urinary output to be in order to maintain adequate hydration?

1. 0.5–2 ml/kg/hr

2. 0.5–2.5 ml/kg/hr

3. 1–3 ml/kg/hr

4. As long as he is having wet diapers it doesn’t matter

ANS: 3

Feedback

1. Urine output is not in normal range

2. Urine output is not in normal range

3. Urine output for the newborn/infant should be 1–3 cc/kg/hr, in the hospital, to maintain adequate fluid maintenance

4. Measuring I & O is important to assess kidney function in a dehydrated patient

KEY: Content Area: Renal/Urinary| Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge |  REF: Chapter 7 | Type: Multiple Choice