A seven-month old infant is admitted with nonorganic failure to thrive (NFTT). To aid the child's
growth and development, which intervention is most important for the nurse to implement?
Encourage the parents to participate in a planned program of play with the infant.
Refer the parents for psychological counseling to identify parental detachment.
Demonstrate feeding strategies and infant cues that indicate hunger and satiation.
Provide instructions about formula preparation and feeding schedules. - ANS Demonstrate
feeding strategies and infant cues that indicate hunger and satiation.
The nurse is triaging a child with a fever brought to the emergency department by the parents.
Which finding requires the nurse's immediate intervention?
Prolonged exhalations.
Thick yellow rhinorrhea.
Frequent nonproductive cough.
Oxygen saturation is 95% by pulse oximeter. - ANS Prolonged exhalations.
The nurse is assessing the coping behaviors of the parents whose child has been recently
diagnosed with a chronic illness. What reaction by the parents is a positive step in the ability to
cope with this new situation?
Endowing the illness with meaning.
Refusing to believe the child is ill.
Entertaining an unrealistic future plan for the child.
Placing complete faith in religion to the point of relinquishing own responsibility. - ANS Endowing
the illness with meaning.
A 15-year-old girl tells the school nurse that she wants to have a baby. How should the nurse
respond?
"Will you be able to support the baby?"
,"Do you have plans to continue school?"
"Have you talked with your parents about this?"
"Can you tell me how your life will be if you have an infant?" - ANS "Can you tell me how your
life will be if you have an infant?"
The nurse is caring for a premature infant who needs an IV access restarted. What action
should the nurse take when using adhesive tape?
Remove adhesives with water, mineral oil, or petrolatum.
Avoid using tape and adhesives until skin is more mature.
Use scissors carefully to remove tape instead of pulling tape off.
Employ solvents to remove adhesives instead of pulling on skin. - ANS Remove adhesives with
water, mineral oil, or petrolatum.
The nurse calculates a 4 ml dose of prescribed digoxin a 9-month-old infant. What action should
the nurse implement?
Mix dose with juice to disguise its taste.
Suspect dosage error and do not give dose.
Check heart rate and administer dose by placing it to the back and side of mouth.
Check heart rate and administer dose by letting the infant suck it through a nipple. - ANS
Suspect dosage error and do not give dose.
The parents of a toddler brought to the clinic for a well-child visit tell the nurse that their child
becomes upset if even the smallest things change in the environment. What information should
the nurse provide the parents?
A child is insecure because trust is not fostered and developed during infancy.
A toddler should be exposed to different routines to promote adapting to new experiences.
Children of this age are comfortable with ritualism and display global thinking.
Objects should be frequently moved in the environment to teach the child to acclimate to
change. - ANS Children of this age are comfortable with ritualism and display global thinking.
,How should the nurse measure the length of a 14-month-old child ?
Standing height.
Prone recumbent position.
Supine recumbent position.
Side-lying position. - ANS Supine recumbent position.
A 5-year-old child who is one day postoperative has bilateral eye patches in place and should
be out of bed. What nursing intervention should be implemented first before leaving the
bedside?
Speak to the child when entering the room.
Allow the child to assist in feeding himself.
Orient the child to the immediate surroundings.
Allow the parents to stay in the room with the child. - ANS Orient the child to the immediate
surroundings.
The nurse observes the interactions of a 2-year-old child who says, "No," even when "Yes" is
what the child really wants to say. The parent says to the nurse, "We, as parents, are such
positive people, why is our child so negative?" How should the nurse respond?
A 2-year-old often acts in the opposite way to get attention.
This age child is testing the limits of the parent's patience.
The toddler is exhibiting an example of ritualistic behavior.
The child is trying to assert autonomy through negativism. - ANS The child is trying to assert
autonomy through negativism.
A newborn who is breastfeeding is diagnosed with galactosemia. What action should the nurse
implement?
Stop the infant breastfeeding.
Add amino acids to breast milk.
, Give galactokinase with breast milk.
Substitute a lactose-containing formula. - ANS Stop the infant breastfeeding.
A 4-year-old child who is ventilator-dependent is receiving tube feedings in the home setting.
The family wants to begin oral feeding of the child, and asks the home health nurse to feed the
child baby food orally. After explaining the risks for aspiration to the family, list in order which
actions the nurse should implement. (Rank in the priority order from first action to last action.)
1. Refuse to feed the child orally, because the risk is too high.
2. Ask the parents to negotiate a change in feeding methods with the healthcare provider.
3. Set additional goals for feeding the child with the parents.
4. Acknowledge the request and then explore with the family the available options for care. -
ANS 1. Acknowledge the request and then explore with the family the available options for care.
2. Set additional goals for feeding the child with the parents.
3. Refuse to feed the child orally, because the risk is too high.
4. Ask the parents to negotiate a change in feeding methods with the healthcare provider.
What is a priority nursing diagnosis for a child in the subacute stage of Kawasaki disease?
Alterations in skin integrity.
High risk for altered tissue perfusion, cardiopulmonary.
Risk for imbalanced body temperature, hyperthermia.
High risk for fluid volume deficit. - ANS High risk for altered tissue perfusion, cardiopulmonary.
A mother brings her 6-month-old infant to the clinic for a well-child checkup. She comments, "I
want to go back to work, but I don't want my baby to suffer because I'll have less time at home."
How should the nurse respond to the mother?
Stay home until the child starts school.
Find a good baby-sitter close to the house.
Let's talk about the child care options that are best for the child.
Go back to work now so the infant will get used to being with others. - ANS Let's talk about the
child care options that are best for the child.
When assessing the breath sounds of an 18-month-old child who is crying, what action should
the nurse take?
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller LEWIS12. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $10.49. You're not tied to anything after your purchase.