3 - Central cyanosis Show pg 530 - When pale blue discoloration of the lips, feet, and palms of the newborn persists for more than 24 hours after birth, it is referred to as central cyanosis. Central cyanosis can be the result of an inadequate supply of oxygen to the alveoli, poor perfusion of the lungs that inhibits gas exchange, or cardiac dysfunction. Because central cyanosis is a late sign of distress, newborns usually have significant hypoxemia when cyanosis appears. Transient tachypnea is a condition in which the newborn has difficulty breathing due to the obstruction of the nasal passage. If the newborn has polycythemia, the newborn's face would have a dark red complexion, but the newborn would not have pale blue lips, feet, and palms. Acrocyanosis is a condition in which the infant shows bluish discoloration of the hands and feet for about 24 hours after birth. Because the newborn in this scenario shows bluish discoloration 48 hours after birth, it indicates that the infant has central cyanosis and not acrocyanosis. 4 - Petechiae scattered over the newborn's body pg 541 - When petechiae are scattered over the newborn's body, this must be reported to the health care provider, as it can indicate an underlying problem, such as a low platelet count or infection. Bruises on the face of an infant born with a nuchal cord is a common finding, as bruising can also occur on the head or neck. Bruising should be monitored, however, because it can increase the risk for hyperbilirubinemia. Periauricular papillomas, also called skin tags, are findings that occur fairly frequently and do not necessarily indicate a problem. Salmon patches, also called stork bites or angel kisses, are usually symmetrical, and the most common sites are upper eyelids, nose, upper lip, and nape of the neck. Therefore, this is a normal finding that does not have to be reported to the health care provider. Child 3 Generally, by 2 ½ years, the child's weight increases by four times the birth weight. The child with a birth weight of 2.5 kg should have 10 kg of body weight by 2 ½ years. Therefore, Child 3 is in need of further assessment for signs of obesity. The body weight of 12 kg indicates a normal finding in Child 1. The body weight of 15.2 kg indicates a normal finding in Child 2. The body weight of 11.2 kg indicates a normal finding in Child 4. Children who are 2 ½-years-old can jump with both feet, stand on one foot momentarily, build a tower of eight cubes, and hold a crayon with their fingers. While assessing an infant, the nurse notices a typical bald spot, a symmetric distortion of the skull, and torticollis. What should the nurse interpret from this assessment? The infant has a bacterial infection. The infant has a vitamin E deficiency. The infant has a vitamin C deficiency. The infant has positional plagiocephaly. The infant has positional plagiocephaly. -Positional plagiocephaly is a condition in which the infant has an oblique or asymmetric head. The fontanels in the skull of an infant are not closed, which makes the skull pliable. The posterior occiput flattens over time if the infant is placed on his or her back during sleep. This leads to the development of an atypical bald spot, asymmetric distortion of the skull, and tightening of sternocleidomastoid muscle leads to torticollis in the infant. At what age should the nurse advise parents to expect their infant to be able to say "mama" and "dada" with meaning? 4 months 6 months 10 months 14 months 10 months An infant's parent reports to the nurse that the infant is very irritable, has difficulty sleeping, and refuses to eat solid foods due to teething. What nursing interventions should the nurse include in the plan of care to make the infant comfortable? Provide hard candy for the infant Give ibuprofen (Advil) to the infant Use frozen liquid-filled teething rings Rub the infant's gums with salicylates Give ibuprofen (Advil) to the infant The nursing student who is posted in the pediatric unit asks the nurse, "Which behaviors would be expected in 8-month-old infants?" Which appropriate answers does the nurse state to the nursing student? "The child can play peek-a-boo." "The child can drink from a cup." "The child exhibits stranger anxiety." "The child can remove some clothing." "The child can stand by holding furniture." "The child can play peek-a-boo." -An 8-month-old infant is not able to drink from a cup or remove clothes. These activities require more muscle coordination, which will not be achieved by the infant at this age. A 12-month-old infant is able to drink from a cup. An 18-month-old infant is able to remove clothes. The
nurse has prepared feeding guidelines for an infant with failure to thrive (FTT). The nurse instructs the student nurse to feed the infant. Which guidelines should the nurse explain to the student nurse before feeding? "Do not stand face-to-face with the infant during feeding." "Provide a quiet, unstimulating atmosphere to the infant." "Continue to talk to the infant while providing the feeding." "Introduce new food on a regular basis in the infant's diet." "Maintain a calm, even temperament throughout the meal." "Provide a quiet, unstimulating atmosphere to the infant." During a home visit, the parents report to the nurse that they are worried about their 3-year-old child's behavior. The child lacks discipline and writes on the walls. Which nursing advice would be helpful for the parents for limiting the child's behavior? "Send the child to his or her bedroom for a time-out." "Instruct the child to stand in play yard for some time." "Seclude the child in the store room for a punishment." "Scold the child in a firm, loud tone for the misbehavior." "Instruct the child to stand in play yard for some time."
As the nurse is assessing an infant, the nurse notices that the teeth are erupting and the infant's skin color is bluish. After assessing oxygenation, the nurse reviews the laboratory report and finds that the infant has methemoglobinemia. What would be the probable reason for this? Application of topical anesthetics Excessive use of cold teething ring Administration of aspirin (Acuprine) Excessive consumption of hard candy Application
of topical anesthetics Which fine motor activity can be observed in a 4-month-old infant? Holding a bottle Grasping objects Playing with a rattle Taking objects directly to mouth Playing with a rattle The nurse assesses that the infant has difficulty breathing, decreased heart rate, change in skin color, and an ill-looking appearance. What should be the first nursing intervention in this situation? Alternate the infant's head position Place the infant in the prone position Place the infant in side-lying position Rub the trunk gently to wake the child Rub the trunk gently to wake the child What are the primary goals in the nutritional management of children with failure to thrive (FTT)? Allow for catch-up growth Correct nutritional deficiencies Achieve ideal weight for height Restore optimum body composition Educate the parents or primary caregivers on child's nutritional requirements Educate the parents or primary caregivers that the child will need tube feedings first Allow for catch-up growth Correct nutritional deficiencies Achieve ideal weight for height Restore optimum body composition Educate the parents or primary caregivers on child's nutritional requirements Which activities are indicative of the teething process in an infant? select all that apply. Increased need for sleep Infant rubbing on the gums Infant biting on hard objects Eating a lot more solid foods Increased sucking on fingers Infant rubbing on the gums Infant biting on hard objects Increased sucking on fingers The nurse is assessing a 4-month-old infant. Which reflex should the nurse expect to find in the infant? Multiple choice question Rooting Crawling Drooling Tonic neck drooling The nurse is teaching nursing students about vaccine administration. Which statement made by the nursing student indicates effective learning? "Vapocoolant spray should apply to the skin after administering the vaccine." "The influenza vaccine should not be administered to the patient with asthma." "All vaccines should be given to adults by using a 25-mm (1-in) length needle." "A 16-mm (5/8-inch) length needle is used to administer the vaccine to newborns." "A 16-mm (5/8-inch) length needle is used to administer the vaccine to newborns." What are the expected physical assessment findings in a 6Able to lift chest and head while on stomach, holding the weight on hands (often occurs by 4 months) Able to pick up a dropped object. Able to roll from back to stomach (by 7 months) Able to sit in a high chair with a straight back.
Which nursing plan of care best meets the needs of a neglected 6What is most important for the nurse to include in the plan of care to best meet the needs of a neglected 6-month-old infant? Provide consistent caregivers who will provide stimulation that is moderate and purposeful.
Which behaviors are expected for an 8 month old infant quizlet?At this age the infant can play peek-a-boo. It is a typical behavior of an 8-month-old infant. The infant can easily understand that the person is still there even when the person is out of sight. An 8-month-old infant exhibits stranger anxiety.
Which fine motor activity does the nurse observe in a 6It is pincer grasp, which is expected at this age. It is palmar grasp, which is expected at this age.
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Which feeding habit would the nurse expect to find while assessing a 6-month-old infant quizlet
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