Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. The nurse in a pediatric clinic is frequently required to administer medications to infants. Which approach will the nurse take when administering an immunization injection?
a. Use a 1-inch needle...
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. The nurse in a pediatric clinic is frequently required to administer medications to infants.
Which approach will the nurse take when administering an immunization injection?
a. Use a 1-inch needle with a maximum of 1.5 mL of fluid.
b. Keep the infant on the caregiver’s lap and use distraction.
c. Explain the medication and the purpose in simple terms to the infant.
d. Immediately comfort the infant with cuddling and patting.
ANS: B
Chapter: Chapter 8 Newborns and Infants
Chapter Learning Objective: 4. Discuss the variations in nursing procedures related to
the care of the newborn and infant.
Page: 158
Heading: Safe and Effective Nursing Care: Understanding Medication—Neonates and
Medication Administration
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Safety Difficulty: Moderate
Feedback
A. This is incorrect. For a small infant, a 5/8-inch needle with a maximum of 0.5 mL
of fluid is used. For larger infants, a 1-inch needle with a maximum of 1.0 mL of
fluid is administered into the vastus lateralis. For adolescents, the nurse should
use a 1- to 1.5-inch needle (22- to 27-gauge) and up to 3 mL of fluid maximum.
B. This is correct. The nurse should approach the infant slowly and at eye level.
Handle the infant gently, keep the infant on the caregiver’s lap, and use
distraction to decrease anxiety.
C. This is incorrect. The nurse may explain the medication and the purpose to the
caregiver but not to the infant.
D. This is incorrect. The parent should be encouraged to comfort the infant with
cuddling and patting. Additional interactions by the nurse at this time are likely
to cause more stress.
PTS: 1 CON: Safety
2. The nurse is teaching a class to parents about emergency care for newborns and infants.
Which comment from a parent indicates a need for additional teaching?
, a. “I will apply gentle tourniquet pressure for serious extremity bleeding.”
b. “The most important behavior is to remain calm and get emergency help.”
c. “A seriously injured child is moved only if they are in a dangerous situation.”
d. “If a seizure occurs, the safest place for the child is on the floor with the head
turned.”
ANS: A
Chapter: Chapter 8 Newborns and Infants
Chapter Learning Objective: 7. Discuss the emergency care of the newborn and
infant.
Page: 160
Heading: Emergency Care for the Infant and Newborn
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Evaluation [Evaluating]
Concept: Health Promotion
Difficulty: Moderate
Feedback
A. This is correct. The parent who describes applying a tourniquet in any manner for
serious extremity bleeding needs additional teaching. When bleeding occurs with
an infant, pressure with a clean cloth needs to be applied to the bleeding site.
B. This is incorrect. Additional teaching is not needed for the parent who
understands the importance of remaining calm and getting help during an
emergency situation.
C. This is incorrect. Additional teaching is not needed for the parent who
understands that a seriously injured newborn/infant should only be moved if in a
dangerous situation. Examples would be a burning building, in a car, or
underwater.
D. This is incorrect. Additional teaching is not needed for the parent who
understands that a seizing newborn/infant should be lowered to the floor and the
head turned to the side. The nurse may remind the parents that nothing is placed
in the mouth of a newborn/infant who is seizing.
PTS: 1 CON: Health Promotion
3. The nurse is providing care for a newborn who was delivered at 34 weeks’ gestation. The
nurse understands the newborn is a greater risk for death or chronic care needs. Which
recommendation does the nurse make to the parent to prevent the newborn from
developing a common complication?
a. Strictly limit the newborn’s exposure to persons outside the family for 6 months.
b. Start a series of palivizumab prophylaxis immunization as advised by the
pediatrician.
c. Strongly express the need for more frequent pediatric visits to prevent
, complications.
d. Reinforce not allowing the premature newborn to cry for more than 10 minutes.
ANS: B
Chapter: Chapter 8 Newborns and Infants
Chapter Learning Objective: 10. Discuss chronic care of the newborn and infant.
Page: 164
Heading: Chronic Care for the Infant and Newborn > Premature Infants
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Health Promotion
Difficulty: Difficult
Feedback
A. This is incorrect. There is no protocol that supports the nurse recommending
strict limitation of the newborn’s exposure to persons outside the family for 6
months. However, the nurse should state that the presence of sick persons, and
public exposure in general, increases the risk of illness in a premature newborn.
B. This is correct. The prevention for respiratory syncytial virus (RSV; a common
complication for premature neonates) is palivizumab (Synagis) prophylaxis
immunization; there are significant benefits to premature infants and infants who
are less than 35 weeks. Palivizumab is given in no more than five monthly doses
during RSV season (late October to late January).
C. This is incorrect. There is no basis for the nurse to strongly express the need for
more frequent pediatric visits to prevent complications.
D. This is incorrect. There is no basis for the nurse to reinforce not allowing the
premature newborn to cry for more than 10 minutes.
PTS: 1 CON: Health Promotion
4. During a parenting class, a father states, “My wife cannot hold the baby without singing a
lullaby, even in public. It’s kind of embarrassing for me.” Which opinion does the nurse
share with the group after researching the topic?
a. Caregivers sometimes sing for their own attention and benefit.
b. The father can walk away from public places if the mother sings.
c. The mother needs to find another way of comforting her baby.
d. Singing of lullabies by caregivers has a calming effect on infants.
ANS: D
Chapter: Chapter 8 Newborns and Infants
Chapter Learning Objective: 13. Discuss alternative/complementary therapies for the
family of the newborn and infant.
Page: 164
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