Pediatrics: assessment
A nurse in the emergency department is caring for an unaccompanied infant following a motor-vehicle crash. During the assessment, the nurse notes that the infant's anterior fontanel is almost closed. She has 6 teeth, is able to sit unsupported, and can drink from a cup. The child cries whenever anyone new to her enters the room, says a few words, and is asking for "mama" and "dada." The nurse should make which of the following age assessments for this child?
12 months old The nurse should know that this infant must be less than 18 months old because her anterior fontanel is still open. The infant is approximately 12 months old due to the presence of 6 teeth. Her skills-sitting unsupported (8 months), drinking well from a cup (9 months), stranger anxiety (8 months), and ability to say 2 words (12 months)-should also help the nurse estimate the infant's age as 12 months
Although the ability to walk independently varies among infants, the nurse should not expect this gross motor skill until the infant is
13 to 15 months of age
The nurse should expect a 24-month-old toddler to have
16 teeth
The nurse should expect the infant's posterior fontanel to be closed at about
2 months of age
A child is typically not able to effectively use scissors until the age of
4
The skill of hopping on 1 foot is not developed until around the age of
4 years
A child is typically not able to complete this task before the age of
5
A child is typically not able to memorize time-associated words until the age of
5
A nurse is assessing a 1-week-old infant at a well-child visit. The nurse should notify the provider about which of the following assessment findings?
A blue coloring of the sclera This discoloration is associated with osteogenesis imperfecta, a genetic disorder that results in bone fragility. The nurse should notify the provider of this finding.
Tympanic temperatures do not provide a precise measurement of an infant's body temperature.
A rectal temperature is the most consistent with an infant's core temperature.
Infants are able to grab the feet and pull them to their mouth at 6 months of age.
At this age, the infant should also be able to pick up a dropped object and hold a bottle.
The toddler is able to state her first and last name is an expected finding in a toddler at the age of 30 months.
At this age, the toddler should be able to state her first and last name.
Completion of primary dentition is an expected finding in a 30-month-old toddler.
At this age, the toddler should have all 20 deciduous teeth.
The infant must be younger than 18 months old since her anterior fontanel is still open.
In addition, an infant of this age should have 12 teeth.
A nurse is performing a physical assessment on a 12-month-old infant. Which of the following findings should the nurse report to the provider?
The infant's current weight is double his birth weight. The nurse should expect a 12-month-old infant's weight to be triple his birth weight; therefore, the nurse should report this finding to the provider.
A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings indicates the need for further assessment?
The infant's legs remain crossed and extended when supine. Legs that are crossed and extended when supine is an unexpected finding and requires further assessment. At 6 months of age, the infant's legs flex at the knees when the infant is supine. Crossed and extended legs when supine is associated with cerebral palsy.
Step 3:
The nurse should notify the provider.
The infant has a closed posterior fontanel is an expected finding in a 6-month-old infant.
The posterior fontanel closes at approximately 2 months of age. The anterior fontanel is closed by 18 months of age.
Stepping
The stepping reflex, in which the infant takes reflexive steps when placed on his or her feet in an upright position, disappears by the age of 4 weeks.
A nurse is assessing a 30-month-old toddler during a well-child visit. Which of the following findings requires further assessment by the nurse?
The toddler's birth weight is tripled. The toddler's birth weight should triple by 12 months of age. By 30 months of age, the toddler's birth weight should be quadrupled.
Step 2:
Then elevate the extremity.
An area of deep blue pigmentation over the buttocks
This discoloration is known as a Mongolian spot. It is typically observed in infants who have increased skin pigmentation (e.g., those of African, Asian, or Hispanic descent) and does not require notification of the provider.
A flat, dark pink area between the eyes that blanches
This discoloration is known as a nevus simplex, or stork bite. It typically blanches with pressure and becomes more prominent with crying. This finding does not require notification of the provider.
A patchy, red rash with raised centers
This discoloration is known as erythema toxicum, or newborn rash. It is a benign, transient finding and does not require notification of the provider.
A nurse is performing a developmental assessment on a 3-year-old child. Which of the following commands should the nurse expect the child to complete successfully?
"Put your shoes on." Children should be able to pull on their shoes when they are 3 years old. They typically cannot tie their shoes until they are 5 years of age.
A nurse is performing an annual physical assessment of a preschooler. The parent expresses concern about the child's 1.8 kg (4 lb) weight gain over the past year. Which of the following responses should the nurse make?
"Your child's weight change is expected for this age group." A preschooler should gain about 2 to 3 kg (4.4 to 6.6 lb) each year. Therefore, the nurse should reassure the parent that this child's weight gain is an expected finding for the age group.
The nurse should expect a 12-month-old infant to have
6 to 8 teeth present
A nurse is caring for an infant who is breastfed and is receiving amoxicillin for an upper respiratory infection. An assessment of the mouth reveals whitish patches on the tongue that will not scrape off. Which of the following actions should the nurse take?
Administer an antifungal medication after feedings The nurse should administer an antifungal medication to the infant after feedings to ensure adequate contact time with the oral mucosa and tongue to enhance treatment of the oral candidiasis.
A nurse is assessing a 6-year-old client at a well-child visit. Which of the following findings requires further assessment by the nurse?
Presence of sparse, fine pubic hair The development of sexual characteristics prior to the age of 9 years in boys and 8 years in girls is an indication of precocious puberty and requires further evaluation.
The nurse should expect a 24-month-old toddler to have
a head circumference that is equal to or less than the chest circumference
The nurse should expect a 24-month-old toddler to have
a vocabulary of about 300 words and to be able to speak in 2- to 3-word phrases
The nurse should expect a 6-year-old child to
have the cognitive ability to identify left and right
The nurse should expect a 3-year-old child to
have the fine motor ability to build a tower of 9 to 10 blocks
The nurse should expect a 5-year-old child to
have the language ability to identify time-related words like the days of the week
Autonomy vs. shame and doubt
is the developmental task of a toddler (ages 12 months to 3 years)
Initiative vs. guilt
is the developmental task of early childhood (ages 3 to 6 years)
Identity vs. role confusion
is the task of the adolescent (ages 13 to 19 years)
At 24 months, an infant should have all of her primary teeth and be able to speak in 2-word phrases.
Ability to build a tower of 6 blocks & Slightly bowed or curved leg appearance The nurse should expect a 24-month-old toddler to be able to stack a short tower of 6 or 7 blocks. Additionally, a 24-month-old toddler will have a "pot-bellied" appearance; the legs should be slightly bowed to support the weight of the comparatively large trunk.
A nurse is assessing the vital signs of a 1-month-old infant. Which of the following actions should the nurse perform?
Count respirations before taking other vital signs It is best to count the infant's respirations while the infant is calm and before being disturbed. The pulse should be taken next, followed by the temperature, which is the most disruptive assessment to an infant.
A nurse is preparing to assess an 11-month-old infant during a well-child examination. Which of the following actions should the nurse take?
Examine the infant's throat at the end of the examination The nurse should perform noninvasive assessments first to avoid causing the infant to cry, which can make the remainder of the examination difficult.
Step 1:
Extravasation is the infusion of vesicant solutions or medications into surrounding tissues. After observing extravasation, the nurse should first stop the infusion.
A nurse is performing a well-child assessment on a 7-year-old client who takes great pride in bringing school papers home. The nurse recognizes that this behavior demonstrates which of the following of Erikson's stages of psychosocial development?
Industry vs. inferiority The developmental task of industry vs. inferiority is reflected by a child's level of motivation in relation to personal achievements that build good character during the school-age years (ages 6 to 12 years).
A nurse is caring for an infant who is experiencing dehydration. Which of the following assessments is the nurse's priority?
Measure the client's weight daily When applying the urgent versus nonurgent priority-setting framework, the nurse should consider urgent findings the priority because they more readily indicate the degree of threat to the client. The nurse may also need to use nursing knowledge to identify which finding is the most critical. Daily weight measurements are the most sensitive indicator of fluid balance in clients of all ages. Daily weight measurements are especially critical for infants and children because fluid accounts for a greater portion of body weight
A nurse is assessing a 6-month-old infant. The guardian reports that the infant does not appear interested in the brightly colored mobile hanging above the crib at home. Which of the following techniques should the nurse use to check the infant's visual acuity?
Move a brightly colored toy from side to side in front of the infant's face The nurse should check the infant's ability to see by positioning the infant upright and holding a brightly colored toy or object in front of the infant's face and moving it from side to side. The nurse should observe the infant's ability to fixate on the toy and track its movement. The nurse can also perform this assessment using the human face as a visual target.
A nurse is assessing an adolescent who is receiving fentanyl via epidural. Which of the following assessments should the nurse identify as the priority?
Oxygen saturation When using the airway, breathing, and circulation (ABC) approach to client care, the nurse should identify that checking the adolescent's oxygen saturation level is the priority. By monitoring the adolescent's oxygen saturation level and respiratory status, the nurse can identify if the client has developed opioid-induced respiratory depression.
Step 4:
Remove the IV line. Treatment of extravasation varies according to the vesicant and might involve the infusion of an antidote through the IV line into the tissues. Therefore, the IV line is not removed until the provider's prescriptions have been initiated.
A nurse is performing a well-child assessment on a 4-year-old child. Which of the following findings should the nurse expect?
The child is able to hop on 1 foot. The nurse should expect a 4-year-old child to have the gross motor ability to hop on 1 foot.
A nurse is assessing a 10-month-old infant at a well-infant checkup. Which of the following assessment findings should the nurse report to the provider?
The infant needs assistance to sit up An infant is expected to have the ability to sit up unsupported around 8 months of age. Therefore, the nurse should report this finding to the provider.
A nurse is assessing a child who sustained a head injury. During the assessment, the nurse observes clear drainage leaking from the child's nose. Which of the following actions should the nurse take?
Test the nasal secretions for glucose The nurse should test the nasal secretions for glucose with a reagent strip to determine if the secretions are a leakage of cerebrospinal fluid (CSF). The leakage of CSF is positive for glucose and occurs if the child has a skull fracture.
Moro
The Moro reflex should disappear at the age of 3 to 4 months. It is an extension of the arms and flexion of the elbows in response to a sudden jarring, followed by flexion and adduction of the extremities.
Extrusion
The extrusion reflex, which causes the infant to spit out food placed on the tongue rather than moving it to the back of the mouth, is absent by the age of 4 months.
A nurse is performing a physical assessment on a 6-month-old infant. Which of the following reflexes should the nurse expect to find?
Babinski The Babinski reflex, which is elicited by stroking the bottom of the foot and causing the toes to fan and the big toe to dorsiflex, should be present until the age of 1 year. Persistence of neonatal reflexes might indicate neurological deficits.
A nurse is assessing a child who is postoperative. Which of the following findings should the nurse identify as an indication that naloxone should be administered?
Respiratory depression The nurse should monitor the child's respiratory status postoperatively and plan to administer naloxone if respiratory depression is present. Naloxone is an opioid antagonist used to reverse the effects of opioids administered perioperatively.
A nurse is assessing a child who is receiving IV chemotherapy. Assessment findings include extravasation of the tissues surrounding the IV insertion site. In which order should the nurse take the following actions? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Stop the infusion Elevate the extremity Notify the provider Remove the IV line
