Chapter 28: Assessment of the Child (Data Collection)

A nurse is assessing a Babinski reflex in a 2-day-old newborn. Which finding by the nurse would indicate a positive finding?

Fanning of the infant's toes A Babinski reflex is part of the neurological assessment of a newborn. When the newborn is touched or stimulated along the lateral side and ball of the foot, the toes fan.

The nurse is examining the posture of a toddler and notes lordosis. What would be the appropriate reaction of the nurse to this finding?

Do nothing; this is a normal condition for toddlers. Toddlers' physical appearance usually include lordosis (swayback) and bowlegs, with a relatively large head and protuberant belly. Thus, this toddler presenting with lordosis is a normal finding and requires no further attention. The toddler does not need a referral to a specialist nor a back brace.

When auscultating bowel sounds, which of the following frequencies would the nurse identify as normal?

Five to 10 per minute The usual frequency of bowel sounds is 5 to 10 per minute.

When assisting with the physical exam of a 1-year-old child, the nurse notes the following findings. Which finding would be concerning to the nurse?

Heart rate of 80 The normal heart rate for a 1-year-old infant is 90 to 170 beats per minute, with an average rate of 120 to 130; a heart rate of 80, therefore, is concerning and needs to be reported to the physician. Clear drainage is a common finding in young children and is not concerning. Ear alignment is normal. Health care providers are only concerned when the ears lie below the level of the eye. Abdominal respirations are quite normal for infants.

A nurse is taking a health history on a new family at the pediatric clinic. Which information is the priority information to gather for a complete history databa

Immunization record Immunization records are important to know in a health history of any child. If the child is missing any immunizations, the nurse can then educate the parents about vaccines and assist in scheduling immunizations. The other choices are important to know when gathering a history, but the immunization history is the priority in this list.

The nurse is measuring the blood pressure of a 12-year-old boy with an oscillometric device. The boy's reading is greater than the 90th percentile for gender and height. What is the appropriate nursing action?

Repeat the blood pressure reading using auscultation. The nurse should repeat the reading using auscultation. The nurse should not use the Doppler ultrasound method in this circumstance. The nurse would only measure the blood pressure in all four extremities with a child presenting with cardiac complaints.

A parent has brought the child into the clinic for a routine health assessment. The parent asks when routine screening for back symmetry will begin. Which response by the nurse is most accurate?

School age Screening for curvatures of the spine begin at school age when the child is most likely to develop this kind of deformity.

A nurse is packing a bag with all of the equipment she will need to perform a complete physical assessment at a client's home. What will the nurse need? Select all that apply.

Thermometer Stethoscope Tongue depressor Ophthalmoscope When performing a complete physical assessment, the nurse will need the following equipment: a thermometer, a stethoscope, a tongue depressor, an ophthalmoscope, an otoscope, a sphygmomanometer, a tape measure, a tuning fork, a reflex (percussion) hammer, examination gloves, and perhaps a client drape or gown. A syringe or IV bag would not be needed.

A 6-month-old has fanning of the toes and dorsiflexion of the big toe seen on physical exam. Based on this finding the nurse should:

document as a normal finding. The infant should be assessed for a Babinski reflex. To achieve this stroke the sole of the foot. Fanning of the toes will occur in infants younger than 3 months of age. A downward reflex of the toes will occur beyond 3 months of age. Some infants will demonstrate a flaring Babinski reflex until 2 years of age. In the absence of other neurologic findings this is a normal response. The nurse would document this normal finding. The child would not need to be referred for further evaluation. The finding does not indicate any particular type shoe the child would require.

A parent brings the child into the clinic and states that the child cannot hear well. Which characteristics in the child may indicate hearing difficulty? Select all that apply.

Responding inappropriately in conversation Speaking loudly Not speaking clearly Not responding when spoken to A high activity level in the child is most likely normal and would not indicate any hearing difficulty. The other choices are all associated with hearing difficulty and would warrant audiometry.

All infants should have their head circumference measured at health assessment visits. Where should the nurse place the tape measure to obtain this measurement?

just above the eyebrows through the prominent part of the occiput To measure the circumference of an infant's head, the nurse would measure the largest point across the skull, not including the ears, with a no stretching cloth or paper tape. The tape would be placed at the forehead just above the eyebrows and brought around the head in a taut circle just above the occiput prominence at the back of the head. The measurement is then marked on a growth chart so it can be plotted to assess adequate growth. Each of the other options depicts incorrect placement of the tape for measurement and would not provide a correct measurement of the head.

A mother brings her 3-year-old daughter to the emergency department because the child has been vomiting and having diarrhea for the past 36 hours. When assessing this child's temperature, which method would be least appropriate?

rectal Obtaining the child's temperature via the rectal route would be least appropriate because the child has diarrhea, and insertion of the thermometer might traumatize the rectal mucosa. Additionally, the rectal route is highly invasive and a child of this age fears body invasion. Using the oral route might be problematic due to the child's age and inability to cooperate, especially in light of the child's vomiting. However, it would not be as dangerous as obtaining a rectal temperature. The tympanic or axillary method would be the most appropriate method.

The nurse begins the physical exam to obtain the child's vital signs. Which would the nurse assess first?

respirations The child's respirations are measured first before any other measurements that may affect the rate.

The nurse is teaching a group of novice nurses how to assess bowel sounds. Which statement will the nurse include in the education?

"Auscultated all four quadrants for a full minute each." During assessment, the nurse should auscultate each quadrant for a full minute when assessing bowel sounds. Therefore, the nurse would include this statement in the teaching. The other statements are inaccurate. Hyperactive bowel sounds are often heard in clients with diarrhea. Bowel sounds should be present within a few hours of life. Bowel sounds are not generally audible with the naked ear.

The nurse is measuring the head circumference of a 1-year-old infant during a well-child visit. The parent asks the nurse why this assessment is being performed. Which response will the nurse provide to the parent?

"Head circumference is typically assessed until age 2 or 3 to help determine if growth is appropriate." Head circumference is typically assessed until age 2 or 3 years to help determine if growth is appropriate. This measurement is plotted on a growth chart to ensure head size is proportional to height/weight growth and to monitor for abnormalities, such as microcephaly or macrocephaly. The nurse will palpate to determine if skull suture lines have fused. The size of the infant's skull is not directly related to intelligence.

The nursing students are learning how to perform a health assessment on a pediatric client. The nursing instructor identifies a need for further teaching when a student states:

"I should take blood pressure on a child beginning at age 2 years." When performing assessments, the nurse does not usually take blood pressure on children younger than 3 years. The recommendations are that blood pressure assessment be done at least once during every health care visit on children aged 3 years and older. Children younger than 3 years should have blood pressure assessed if they have a history of prematurity, have congenital heart defect, have a urinary tract infection, take any medications that influence the blood pressure or have increase intracranial pressure. Blood pressure measurement on hospitalized children is taken according to hospital policy no matter what age. The nurse should always establish good rapport with the child's parents. The nurse would use an electronic thermometer to take a temperature on a child who is 3 years.

The nurse prepares to complete a health history. Which question(s) will the nurse use to best assess the child's lifestyle? Select all that apply.

"What grade are you in?" "How many brothers and sisters do you have?" "What kind of foods do you eat?" "What do you like to do for fun?" Assessment of the child's lifestyle is an aspect of the client history. School history, social history (including number of siblings), personal history (likes and dislikes), and nutrition history (types of food eaten) are all aspects of the lifestyle assessment. Allergy assessment is not an aspect of the child's lifestyle; rather, this is covered in the allergies, medications, and substance use portion of the assessment.

The clinic nurse is interviewing a parent about the infant's illness and is in the chief concern part of the health interview. Which question will the nurse ask during this part of the interview?

"Why did you bring your infant to the clinic today?" The chief concern deals with the reason the parent brought the child to the health care agency at this time. Asking "why did you bring your infant to the clinic today" addresses this concern. No other question addresses this concern.

Blood pressure monitoring becomes part of the routine health assessment at what age?

3 years Blood pressure monitoring becomes part of the routine health exam at age 3.

The nurse is caring for a toddler who was just diagnosed with a hearing impairment. What would the nurse expect to assess in the child?

A delay or lack of clear, understandable speech pattern A hearing impairment will often cause a delay or absence of normal speech and language development in a child. Toddlers typically do not vocalize the sounds of the letter 'R" and "S" until older. Purulent drainage may represent an ear infection. Oxygen at birth may be problematic for vision, but not hearing.

The nurse is interviewing an adolescent. What should the nurse recognize as an important aspect of interviewing the adolescent?

Adolescents will share more about themselves in a private conversation. All children need the opportunity to actively participate in the health history and assessment process. Adolescents may not feel comfortable addressing health issues, answering questions or being examined in the presence of parents or caregivers. Interviewing them in private often encourages them to share information that they might not contribute in front of their caregivers. Assuring the adolescent that anything shared or discussed will be confidential allows him or her to better discuss sexual needs or use of substances. Adolescents also would rather not have a peer present because they do not want to be seen as different from their peers and there is also the issue of confidentiality.

The nurse is conducting a health history for a 9-year-old child with stomach pains. What is a recommended guideline when approaching the child for information?

Allow the child to control the pace and order of the health history. The nurse should elicit the child's cooperation by allowing him or her control over the pace and order of the health history, or anything else that the child can control while still allowing the nurse to obtain the information needed. A white examination coat or all-white uniform may be frightening to children, who may associate the uniform with painful experiences or find it too unfamiliar. The nurse should use slow, deliberate gestures rather than very quick or grand ones, which may be frightening to shy children. The nurse should make physical contact with the child in a nonthreatening way at first by briefly cuddling newborns before returning them to caregivers, laying a hand on the head or arm of toddlers and preschool-age children, and warmly shaking the hand of older children and adolescents to convey a gentle demeanor.

A 4-year-old is ordered to have a hearing test. How should the nurse best prepare the child for this exam?

Allow the child to play with the tuning fork. To conduct the Weber test for hearing function the nurse would strike a 500-Hz tuning fork and hold the stem of it against the top of the child's head. The child with normal hearing in both ears will hear the sound equally well with both ears. If the child has an air conduction loss in one ear, the child will hear the sound better in that ear rather than the good ear. The test is used in conjunction with other evaluation tools because if the sound is intensified in one ear, it may mean that there is no hearing perception (i.e., there is nerve loss) in the opposite ear. Explaining and demonstrating the procedure to the child may be important, but developmentally the child needs to be able to see, feel, and hear all equipment being used.

The nurse obtains a rectal temperature for an 11-month-old infant. Which action will the nurse perform?

Apply water-soluble lubricant to the probe. Applying a lubricant to the thermometer probe will help prevent pain or damage to the rectum. The correct distance to insert a rectal thermometer is no more than 1 in (2.5 cm). Inserting the probe too far can damage or perforate the rectal mucosa. An 11-month-old infant is too young to understand explanation of procedures. If resistance is felt, the nurse should not continue advancing the thermometer probe.

The nurse wants to find out how much time a preschooler spends in various activities throughout the day. What should the nurse do to learn this information?

Ask the parents to complete a day history. The child's current skills, sleep patterns, hygiene practices, eating habits, and interactions with the family can all be elicited by asking a parent to describe a typical day. Day histories are fun to obtain because most parents are eager to describe a day with their child, and information gained this way is surprisingly rich and pertinent, much more so than if parents are just asked how their child sleeps, eats, or plays.

The nurse enters a room to perform an assessment and finds the 9-month-old client asleep in the father's arms. Which action will the nurse take first?

Assess the infant's respiratory status. The best time to count a child's respirations is when the child is quiet and calm; therefore, the nurse would assess the client's respiratory status. The nurse would obtain assessment data needed at this time, then return to complete the assessment once the client is awake.

The nurse preceptor observes a novice nurse perform a pediatric assessment. Which action by the novice nurse will the nurse preceptor determine is a normal variance to assessment technique when compared to the assessment of an adult patient?

Assessing the abdomen before assessing the head and neck The only difference with a pediatric assessment versus an adult assessment is that the pediatric assessment may not always be performed in a head-to-toe fashion. Assessing the abdomen before assessing the head and neck may be completely appropriate, depending on the patient's condition. This would not require follow-up by the preceptor. Pediatric assessment includes a review of systems and focused exam and is performed on every patient. Assessing the mental status before the lungs follow the head-to-toe fashion and is not considered a normal deviance to the assessment.

The nurse is preparing to conduct a physical examination of a 3-year-old child. Which assessment will the nurse introduce for the first time to this client?

Blood pressure recording Blood pressure measurement begins to be a part of routine assessment at 3 years of age. The preschool E-chart is used for vision screening at this age. Walking gait and standing height measurement will be introduced in future assessments.

A hospitalized child has a pulse oximeter attached to his finger. What interventions would the nurse implement in caring for this client?

Check the skin under the probe every 2 hours for tissue perfusion. Skin under a pulse oximetry probe needs to be checked every 2 hours to monitor tissue perfusion. Probe sites are changed every 4 hours. Alarms are checked at the beginning of the shift, not at the end. If the child has a continuous pulse oximetry probe, it is checked every 2 hours to be sure the probe is secure.

While performing an assessment on a child, the nurse notes the child's caregiver avoids eye contact with the nurse and is very soft spoken. Which action by the nurse is best?

Continue with the assessment The nurse should continue with the assessment because the caregiver's behavior may likely be a cultural behavior. There is no indication that the nurse needs to report or document the caregiver's behavior or ask the caregiver about the behavior.

The pediatric nurse is performing a head-to-toe exam on a 2-year-old child during a well child assessment. Which method will the nurse use to accurately determine the child's heart rate?

Counting the apical rate The most accurate way of determining the child's heart rate is to count the apical rate by auscultation. The remaining answer choices do not represent the most accurate method to determine the child's heart rate.

The novice pediatric nurse prepares to assess a young child. Which action(s) will require the intervention of the nurse preceptor? Select all that apply.

Counting the pulse rate by palpating the radial pulse for one minute Counting the respiratory rate by auscultating the breath sounds for 30 seconds Various positions of cuff placement and auscultation area for obtaining blood pressure on a young child includes the upper arm (brachial), lower arm (radial), thigh (popliteal), and the calf/ankle (dorsalis pedis). To obtain the chest circumference of the young child, the nurse will use a tape measure at the nipple line. Using the Glasgow coma scale to assess the neurological status of the young child is a correct action that would not require the action of the nurse preceptor. The best way for the nurse to obtain the pulse rate of the young child is to auscultate the apical pulse for one minute. Additionally, the nurse should count the respiratory rate by auscultating the breath sounds for one full minute, as infants and young children often have irregular respiratory rates.

A 6-month-old infant is admitted to the hospital because of a fever. When the nurse obtains a health history, what data would be obtained first?

Details about the fever When the child has an acute problem, it is important to first obtain the chief complaint. This is the reason the child is brought to the health care provider. The nurse would then ask further questions about the onset, the duration, the characteristics and the course of the problem. The family history, history of past illnesses, and a review of the systems would come later in the process of obtaining the health history.

When performing a physical examination on a child, the nurse notes a mirror image in the shape and position of the child's chest and abdomen. Which nursing action is appropriate?

Document the finding in the medical record. The mirror image in shape and position from one side of the body to the other is known as symmetry and is an expected finding. The nurse would document the finding and continue with the assessment. There is no need to notify the provider, measure the chest or abdomen, or assess bowel sounds based on this finding.

The registered nurse (RN) observes the unlicensed assistive personnel (UAP) take a rectal temperature on a 6-month-old client diagnosed with diarrhea. Which action by the RN is appropriate?

Educate the UAP on when to avoid taking rectal temperatures The RN would educate the UAP on when to avoid taking a rectal temperature, such as on an immunosuppressed client or a client with diarrhea, a bleeding disorder, or a history of rectal surgery. The unit manager would not have to be immediately notified, nor would an error report have to be completed. The temperature would not need to be reassessed at this time.

A nurse is performing a health history on a 6-year-old child with asthma. When it comes to identifying if the child is up to date on the immunization schedule, which question would be avoided as it is considered leading?

Have you kept the child up to date on all of the immunizations suggested? A leading question supplies its own answer. This question implies that the child should have had the immunizations and perhaps that the parent is a poor caregiver if he or she gives a different answer than yes. Further, the parent may not be aware of all the current immunizations for the child's age and may inadvertently give an incorrect answer. Asking about the last immunizations is appropriate. Offering to review the immunization record is part of anticipatory guidance. It is important to know if the child had any reactions to the last immunizations to determine whether the child should receive that immunization again.

The nurse is teaching the student nurse how to perform a physical assessment based on the child's developmental stage. Which statement accurately describes a recommended guideline for setting the tone of the examination for a school-age child?

Include the child in all parts of the examination; speak to the caregiver before and after the examination. For a school-age child, the nurse should include the child in all parts of the examination, and speak to the caregiver before and after the examination. For a newborn, the nurse should keep up a running dialogue with the caregiver, explaining each step as it is done. The nurse should speak to the early teen using mature language and appeal to his or her desire for self-care. For an infant, the nurse should address the child by name, and speak to the caregiver and do the most invasive parts last.

What is the first action that a nurse performs when conducting a client interview with a 5-year-old child and the caregiver?

Introduce yourself to the child and caregiver. Establishing rapport with the family begins by introducing yourself to them. This is the first thing a nurse does upon entering the room. Vital signs are obtained either before or after the interview but are not part of the interview. Asking questions of the caregiver instead of handing them a form allows the nurse to talk to them and observe their reactions to the questions. Providing diversional activities for the child is a good idea but is not the first thing done.

When performing a lower extremity assessment which manifestation would be most important for the nurse to evaluate further?

Limping The child should be assessed for range of motion in all the lower extremity joints, gait, and limping. Children who limp need further evaluation. A limp can be due to something simple (such as a blister on the foot from wearing new shoes) or it can also be a sign of a serious hip or bone condition. The joints should have full range of motion. This is important to check for developmental dysplasia of the hip in the infant. When assessing for gait, the nurse would see a wide-based gait in the toddler and may not get an accurate gait in the adolescent if he or she slouches while walking.

To obtain an accurate heart rate in an infant, what would be most important for the nurse to do?

Take the apical pulse. Taking the apical pulse with a pediatric stethoscope and counting the rate for a full minute is the most accurate way to obtain the heart rate on an infant. The radial pulse should only be taken with older children, as it is difficult to palpate accurately in children younger than 2 years of age because the blood vessels lay close to the skin surface and are easily obliterated. An electronic stethoscope is not necessary to listen to heart sounds and count an apical pulse.

The nurse is planning an education session for adolescent males on health promotion activities. Which topic should the nurse include as being the most applicable for this population?

Testicular self-examination Starting in adolescence, all males need to perform testicular self-examination once a month. This is the health promotion activity in which the nurse should focus for this educational session. The reproductive cycle might be more appropriate for adolescent females. Immunization schedule and socialization would be more appropriate for younger children and parents.

The nurse is gathering data on a child being admitted. Which would be considered collecting subjective data? Select all that apply.

The nurse interviews the child's caregiver. The nurse asks questions about the child's history. The nurse finds out the reason for the child's visit to the health care setting. Most subjective data are collected through interviewing the family caregiver and the child. Subjective is the data collected from another source or data that the nurse can not assess, such as pain. No one can feel the pain the client is experiencing. Objective data is information which can be gathered by direct assessment. Getting the necessary information from the caregiver would be a form of subjective data. Taking the vital signs and visual inspection are forms of objective data.

The nurse is weighing a 20-month-old child who is in the clinic for a well-child visit. Which action by the nurse would be most appropriate for weighing this child?

The nurse should have the child sit on the scale while keeping a hand close to but not touching the child. The child who is able to sit can be weighed while sitting. Keep a hand within 1 in (2.5 cm) of the child at all times to be ready to protect the child from injury. Weighing the parent alone and then holding the child will not provide an accurate weight. Accurate weights are needed for medications and treatments. Holding the child's hands will cause a change in the weight and should not be done.

The nurse is taking a respiratory history of a newly admitted child. While documenting the symptoms the child has, what other item is important to document when taking a history on an altered respiratory status?

The triggers in the environment When assessing a respiratory history, it is very important for the nurse to find out what in the environment worsens the child's symptoms. These are called "triggers." The other choices would be part of a general health history.

The nurse is taking the health history for a toddler in the emergency department. The child's parent informs the nurse that the toddler has been vomiting for the last 3 days, has a history of asthma, and was hospitalized with pneumonia and a urinary tract infection (UTI) 6 weeks ago. What would the nurse recognize as is the client's chief concern/complaint?

Vomiting The chief concern/complaint is the reason that the client is seeking current health care and, in this case, is vomiting. The pneumonia, UTI, and asthma are part of the medical history and may or may not have any bearing on why the child is currently sick. These are valid pieces of information and may give the nurse a better picture of the family and child's situation.

The nurse is assessing the heart rate of a healthy 13-month-old child. The nurse knows to auscultate which site to obtain an accurate assessment?

apical pulse at the third or fourth intercostal space For children younger than 2 years of age, the nurse should auscultate the apical pulse with the stethoscope at the point of maximum intensity just above and outside of the left nipple at the third or fourth intercostal space. The radial pulse is difficult to palpate accurately on children younger than 2 years of age because the blood vessels lie so close to the skin surface and are easily obliterated. The brachial pulse is not the best point of auscultation. The point of maximum intensity (PMI) is heard best at the fourth or fifth intercostal space at the midclavicular line beginning around 7 years of age.

The nurse is performing an examination of the eyes of a 7-year-old child. Which finding would indicate that the third cranial nerve is intact?

pupil constriction in response to light If the pupil constricts (reduces in size) in response to the light, it is confirmation the third cranial nerve is intact; it should not dilate. The eyelid blinking in response to touching the cornea with a wisp of cotton is a test of the blink reflex, but should not be performed in children, as it can be painful and frightening to them. During a Hirschberg test, the light of an otoscope should reflect evenly off both pupils if they are in equal alignment.

The nurse is performing a physical examination on a sleeping newborn. Which body system should the nurse examine last?

throat If the infant is asleep, the nurse should auscultate the heart, lungs, and abdomen first while the baby is quiet. The nurse performs the assessment in a head-to-toe manner, leaving the most traumatic procedures—such as examination of the ears, nose, mouth, and throat—until last.

The nurse is assessing the abdomen of a 3-year-old. Which finding should be reported immediately?

visible peristaltic waves Visible peristaltic waves are abnormal and require further evaluation. The other findings are considered normal for the child's age.