Peds -Health Assessment of Children

The nurse examines a 3-year-old girl in a health maintenance setting. What is the first question the nurse would ask her mother to obtain a health history? a) "Is your daughter ill in any way?" b) "Has your daughter been ill in the past?" c) "Do you have any concerns about your daughter?" d) "Tell me about your daughter."

"Do you have any concerns about your daughter?"

When questioning a 15-year-old about his or her health history, what would be an appropriate way for the nurse to ask about the child's drug history? a) "Have you heard that some teens like to smoke? Have you tried this?" b) "Have you smoked cigarettes?" c) "Have you had alcohol at parties before?" d) "Have you smoked crack before?"

"Have you heard that some teens like to smoke? Have you tried this?"

A nurse is caring for a very shy 4-year-old girl. During the course of a well child assessment, the nurse must take the girl's blood pressure. Which approach is best? a) "May I take your blood pressure?" b) "Will you let me put this cuff on your arm?" c) "Help me take your dolls blood pressure" d) "Your sister did a great job when I took hers"

"Help me take your dolls blood pressure"

The nursing students are learning how to perform a health assessment on a pediatric patient. The nursing instructor identifies a need for further teaching when a student makes which of the following statements? a) "I should establish good rapport with the child's parents before beginning an assessment on a child." b) "I should take blood pressure on a child beginning at age 2 years." c) "I should take blood pressure on a child beginning at age 3 years." d) "I should take a temperature using an electronic thermometer beginning at age 3 years."

"I should take blood pressure on a child beginning at age 2 years."

The nurse is preparing to assess the internal ear structures of a 3-year-old. The child is resistant to the otoscope. How should the nurse respond? a) "Come, sit on this pretty, little red chair." b) "May I please look inside your ears?" c) "Please sit still so I can see inside your ears." d) "Let's see if I can find some puppies or kittens."

"Let's see if I can find some puppies or kittens."

The nurse is preparing to see a 14-month-old child and needs to establish the chief purpose of the visit. Which approach with the parents would be best? a) "What is your chief complaint?" b) "Has your child been exposed to infectious agents?" c) "What can I help you with today?" d) "Is your child feeling sick?"

"What can I help you with today?"

When the nurse performs her head-to-toe assessment on a 2-year-old child, when would she examine the child's ears? a) At the start to get it over with b) At the end of the exam in case the child gets upset c) When examining the head and face d) After she is finished examining the entire head and face

At the end of the exam in case the child gets upset

Which technique would you begin with to assess a child's abdomen? a) Palpation b) Inspection c) Auscultation d) Percussion

Inspection

The nurse is measuring the head circumference of a child. Which of the following is accurate related to this procedure? a) Place the tape measure around the head with the tape touching just below the eyes. b) Expect the head circumference and the chest circumference measurements to be equal up to the age of 6 years. c) Place the tape measure around the head just above the eyebrows. d) Measure the head circumference routinely on children up to the age of 6 years.

Place the tape measure around the head just above the eyebrows.

The nurse is conducting the Denver Articulation Screening with a 5-year-old girl to assess her speech. Which of the following should the nurse do while conducting this exam? a) Convey the impression that there are no right or wrong answers b) Modify the directions of the test using the nurse's own discretion c) At the end explain which words the child missed and why d) Have the child read each of the 22 words from a sheet of paper

Convey the impression that there are no right or wrong answers

A sleeping 5-month-old girl is being held by the mother when the nurse comes in to do a physical examination. What assessment should be done initially? 1. Listening to the bowel sounds 2. Counting the heart rate 3. Checking the temperature 4. Looking in the ears

Counting the heart rate

The human papillomavirus (HPV) is associated with the development of cervical cancer in women. a) False b) True

True

A 5-year-old boy visits the physician's office with an upper respiratory infection. Which approach would give the nurse the most information about the child's developmental level? 1. Playing a game with the child 2. Talking with the child about the teddy bear next to him 3. Using a screening tool during a follow-up office visit 4. Asking the 10-year-old sibling about the child

Using a screening tool during a follow-up office visit

When obtaining a child's health history the child's biological data is assessed. What is the next thing to assess in the child's history? a) Types of medications the child is on b) The chief complaint of the child c) How the child feels school is going d) History of illness

The chief complaint of the child

Question: The experienced nurse is assessing the child's lungs. Rank the following steps in the proper order of assessment. 1 The nurse palpates the child's thorax. 2 The nurse auscultates the child's lungs. 3 The nurse percusses over the child's lungs. 4 The nurse visually inspects the child's thorax.

The nurse visually inspects the child's thorax. The nurse palpates the child's thorax. The nurse percusses over the child's lungs. The nurse auscultates the child's lungs.

When testing the deep tendon reflexes of a child, a four-point grading scale is used. What would a 1+ result mean for a reflex tested? a) The reflex is absent. b) The reflex is hyperactive. c) The reflex is diminished. d) The reflex is brisk.

The reflex is diminished. 1+ indicates a diminished response. 2+ as average 3+ is brisker than average 4+ is hyperactive. The reflex is absent at a grade of 0

The mother of 2-year-old triplets is anxious and worried because one of the children does not seem to be at the same developmental level as her siblings. Which finding might indicate a need for further diagnostic testing to rule out intellectual disability in this child? a) She blows her nose frequently. b) The tops of her ears are below the corners of her eyes. c) She speaks loudly when asked a question. d) The fontanels on her head are closed.

The tops of her ears are below the corners of her eyes.

While examining a child, the nurse notes quiet, soft sounds each time the stethoscope is moved over the child's chest. The nurse knows that these are not breath sounds. What actions should the nurse take? (Select all that apply.) a) Refer the child for further evaluation. b) Record the location and timing of the sounds. c) Conclude this is a grade 3 heart murmur. d) Auscultate with the child lying down. e) Auscultate with the child sitting up.

• Record the location and timing of the sounds. • Auscultate with the child lying down. • Auscultate with the child sitting up. • Refer the child for further evaluation.

The nurse is taking vital signs on a 6-month-old infant. The caregiver reports that over the past 12 hours, the child has had vomiting, diarrhea, and has been pulling on his ears. Which methods would be appropriate for taking this child's temperature? Select all that apply. a) Axillary b) Oral c) Temporal d) Tympanic e) Rectal

• Temporal • Tympanic • Axillary

A nurse realizes the importance of nutritional assessment during the health history. When doing so, the nurse must assess the quality as well as quantity of food eaten. The best way to assess food intake is to do which of the following? a) 24-hour recall b) 1-week recall c) 12-hour recall d) 3-day recall

24-hour recall

When assessing for bowel sounds, which of the following is true? a) Bowel sounds should be audible by the naked ear unless distention is present. b) Bowel sounds should be heard at a rate of 80 to 90 per minute in the lower quadrants. c) The presence of high-frequency sounds at 5- to 10-second intervals is abnormal. d) All four quadrants should be auscultated in a consistent pattern.

All four quadrants should be auscultated in a consistent pattern.

Which assessment finding is considered normal in children? 1. Irregular respiratory rate and rhythm 2. Split S2 and sinus arrhythmia 3. Decreased heart rate with crying 4. Genu varum past the age of 5 years

Split S2 and sinus arrhythmia

The nurse needs to calculate the child's body mass index (BMI). The child's weight is 42 kg. The child is 142 cm in height. Calculate the child's BMI using the metric method. Record your answer using a whole number. ______BMI

21 the formula is: weight in kilograms divided by height in meters squared weight (kg)/height (m)2 42 kg/1.42 squared 42/2.0164 = 20.8292 Rounded to 21

The emergency department nurse is caring for a child who is showing signs of anaphylaxis. The nurse evaluates how comprehensive the history of the child should be and determines that which action takes priority? a) Stabilizing the child's physical status b) Getting the child's history from other providers c) Obtaining a complete and detailed history d) Taking a problem-focused history

Stabilizing the child's physical status

The nurse is taking an apical pulse on an infant. The nurse should place the stethoscope at which of the following sites? a) Between the sternum and the left nipple b) Below the ribs about one half of an inch c) Above the sternum, slightly to the right d) Above the clavicle on the left side

Between the sternum and the left nipple

Which of the following assessments would you expect to introduce for the first time in the physical examination of a 3-year-old child? a) Snellen vision testing b) Blood-pressure recording c) Standing height measurement d) Observation of walking gait

Blood-pressure recording

While interviewing a mother about her infant son's illness, the nurse asks, "Why did you bring Clark to the clinic today, Ms. Donovan?" Which part of the health interview is this nurse currently in? a) Chief concern/complaint b) Health and family profile c) Day history d) Demographic data

Chief concern/complaint

Parents bring a toddler age 19 months to the clinic for a regular checkup. When palpating the toddler's fontanels, what should the nurse expect to find? a) Open anterior and posterior fontanels b) Open anterior fontanel and closed posterior fontanel c) Closed anterior fontanel and open posterior fontanel d) Closed anterior and posterior fontanels

Closed anterior and posterior fontanels

What approach by the nurse would most likely encourage a child to cooperate with an assessment of physical and developmental health? 1. Explain to the child what's going to happen when the child asks questions. 2. Explain what is going to happen in words the child can understand. 3. Force the child to cooperate by having a parent hold him or her down. 4. Give the child a sticker before beginning the examination.

Explain what is going to happen in words the child can understand.

Anna is 4 years old and complains of ear pain. To examine Anna's ear, how should the nurse proceed? a) Grasp the pinna and look inside. b) Grasp the pinna and pull down and back. c) Grasp the pinna and pull up and back. d) Grasp the pinna and pull forward.

Grasp the pinna and pull up and back.

The nurse is examining an infant who is 4 days old. The nurse puts the infant in a semi-upright position and lets the head fall back (with immediate support). What infant reflex is the nurse testing for? a) Babinski b) Moro c) Palmar grasp d) Startle

Moro

The nurse is conducting a physical examination of a healthy 6-year-old. Which action should the nurse do first? a) Observe the skin for its overall color and characteristics b) Palpate the skin for texture and hydration status c) Tap with the knee with a reflex hammer to check for deep tendon reflexes d) Auscultate the heart, lungs, and the abdomen

Observe the skin for its overall color and characteristics

A nurse conducted a health history with a 5 year old admitted with abdominal pain. The nurse stood at the bedside while talking to the mother and child. The patient was in a private room. The nurse made sure the door was closed and referred to the mother as "Mrs. Smith" whenever asking a question. Which of the following actions by the nurse was not conducive to the health history? a) Closing the door b) Conducting it in a private room c) Standing at the bedside d) Referring to the mother as Mrs. Smith

Standing at the bedside

When doing a health assessment on a child, the nurse should include a physical assessment. What is the most important thing to assess first when performing the physical assessment? a) Blood pressure b) Respirations c) Temperature d) Lung sounds

Respirations

The nurse is auscultating the heart of a 6-month-old. Which finding would warrant further investigation? a) A split S2 at the apex b) Variation in heart rate during the 60 second auscultation c) Heart rate of 120 d) S1 varies in intensity.

S1 varies in intensity.

The nurse is conducting a skin assessment of a newborn. The examination reveals a light pink macule on the back of the neck. The nurse understands that this is a normal variation and is most likely which type of birthmark? a) Petechiae b) Nevus flammeus c) Purpura d) Salmon nevus

Salmon nevus

Assessing skin in children is an important factor and good indicator of their overall condition. Which of the following describes cyanosis of the skin? a) Skin that is pink b) Skin that is bluish c) Skin that is an olive-tone d) Skin that is yellowish

Skin that is bluish

The nurse is conducting a physical examination of a 5-year-old girl. The nurse asks the girl to stand still with her eyes closed and arms down by her side. The girl immediately begins to lean. What does this tell the nurse? a) The child has a negative Romberg test; no further testing is necessary. b) The child has poor coordination and poor balance. c) The child warrants further testing for cerebellar dysfunction. d) The child warrants further testing for an inner ear infection.

The child warrants further testing for cerebellar dysfunction.

The nurse is examining the heart and peripheral perfusion of an 8-year-old. The nurse will assess the apical impulse at which location? a) The fifth intercostal space medial to the left midclavicular line b) The fourth intercostal space just medial to the child's left midclavicular line c) The fifth intercostal space lateral to the left midclavicular line d) The fourth intercostal space at the left midclavicular line

The fifth intercostal space lateral to the left midclavicular line

The nurse is assessing the Babinski sign in a 3-day-old infant. What is a normal response? a) The infant's foot moves back and forth. b) The infant's toes stay in the normal position and the big toe has dorsiflexion. c) The infant's toes fan and the big toe has dorsiflexion. d) The infant's toes wiggle.

The infant's toes fan and the big toe has dorsiflexion.

A child on a cardiac monitor has been transported from the emergency room to the intensive care unit. The nurse admits the child to the unit and begins collecting data on the child. Which of the following nursing interventions would the nurse do first? a) Change the probe on the pulse oximeter. b) Verify that the alarms on the monitor are still properly set. c) Assess the neurological function using the Glasgow coma scale. d) Check the apical pulse rate using a pediatric stethoscope.

Verify that the alarms on the monitor are still properly set.

The nurse is assessing the abdomen of a 3-year-old. Which finding should be reported immediately? a) Active bowel sounds b) Tympany over the abdomen c) Rounded abdomen d) Visible peristaltic waves

Visible peristaltic waves

As Julie performs her head-to-toe assessment on a 2-year-old child, when would she examine the child's ears? a) When Julie is first starting so as to get it over with b) When Julie is done with all of the exam in case the child gets upset c) When Julie is examining the head and face d) When Julie is finished examining the entire head and face

When Julie is done with all of the exam in case the child gets upset

When is the best time for the nurse to count a 9-month-old's respirations? a) When he is quiet in his mother's lap b) When he is laughing c) When he is in the playroom d) When he is crying

When he is quiet in his mother's lap

The nurse is taking health history for a toddler in the emergency department. The child's mother 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 6 weeks ago. What would the nurse recognize as is the patient's chief concern/complaint? a) pneumonia b) asthma c) UTI d) vomiting

vomiting

Anthropometric measurements help determine: a) how well a child grows. b) how fast a child can run. c) how well a child sleeps. d) what grade a child should be in.

how well a child grows.

All infants should have their head circumference measured at health-assessment visits. This measurement is made from a) the center of the forehead to the base of the occiput. b) the hairline in front to the hairline in back. c) just above the eyebrows through the prominent part of the occiput. d) the middle of the forehead through the parietal prominences.

just above the eyebrows through the prominent part of the occiput.

When assessing symptoms such as rashes, pain, or lesions, what would be included in the location factor of the symptom? a) amount b) quality c) localized or generalized d) color

localized or generalized

A nurse is conducting a physical examination of an uncooperative preschooler. In order to encourage deep breathing during lung auscultation what could the nurse say? a) "You must breathe deeply so I can hear your lungs." b) "You may not leave until I listen to your breathing." c) "Do you want your mother to listen to your lungs?" d) "Do you think you can blow out my light bulb on this pen?"

"Do you think you can blow out my light bulb on this pen?"

Fourteen-year-old Freddy has come to his primary-care physician's office for a routine well-child visit. In reading the child's history, the nurse notes that Freddy's father suffers from alcoholism. If Freddy's mother makes the following statements, which statement would be most important for the nurse to gather further data regarding? a) "Sometimes Freddy asks me questions about his father's low tolerance for alcohol." b) "I think I know how Freddy feels about drinking. He has had substance abuse education in school." c) "Our next door neighbor is older than Freddy, and he drinks when they hang out together." d) "I wish there was a blood test for alcoholism. I know Freddy is at risk."

"Our next door neighbor is older than Freddy, and he drinks when they hang out together."

The nurse is caring for a 10-year-old girl and is trying to obtain clues about the child's state of physical, emotional, and moral development. Which question is most likely to elicit the desired information? a) "Do you like your school and your teacher?" b) "Would you say that you are a good student?" c) "Tell me about your favorite activity at school?" d) "Do you have a lot of friends at school?"

"Tell me about your favorite activity at school?"

The nurse is gathering data from the caregiver of 3-year-old Jared who was heard complaining that he was nauseated while sitting in the waiting room. In interviewing the child's caregiver, which of the following would be the most appropriate initial question for the nurse to ask the caregiver? a) "Has Jared had anything to eat that he might be allergic to?" b) "How often does Jared complain of being nauseated?" c) "Does anyone else in the family have the same symptoms?" d) "What caused you to decide to bring Jared to the clinic today?"

"What caused you to decide to bring Jared to the clinic today?"

A nurse is interviewing a father regarding his 2-year-old daughter's recent illness. The nurse would like the father to elaborate about any symptoms of the illness that he has noticed. Which of the following would be the most effective question for the nurse to ask the father in this situation? a) "Has your daughter exhibited a fever and vomiting?" b) "Your daughter hasn't exhibited a fever, has she?" c) "What symptoms has your daughter exhibited?" d) "Has your daughter exhibited any symptoms?"

"What symptoms has your daughter exhibited?"

The nurse is visualizing the ear canal and tympanic membrane of a 14-month-old boy. Which finding would warrant further investigation? a) A bubble behind the tympanic membrane b) A gray tympanic membrane c) A mobile tympanic membrane d) A pearly pink membrane e) Visible bony landmarks behind the membrane

A bubble behind the tympanic membrane

A nurse is examining the skin of a 15-year-old girl. Which of the following findings should most warrant concern on the part of the nurse? a) A very dark mole with an uneven border b) A rash due to an allergic reaction to cosmetics c) A few acne lesions on the back d) A tattoo on the wrist, with no signs of inflammation

A very dark mole with an uneven border

When 12-year-old Chelsie comes in for her annual check-up, the nurse must take a health history and do a physical exam. What is the most appropriate manner for the nurse to obtain a health history? a) Ask Chelsie to fill out the health form and return it herself. b) Ask Chelsie if she minds if her mother is in the room with her. c) Ask Chelsie's mom to leave the room. d) Ask Chelsie to wait outside while the nurse talks with her mother.

Ask Chelsie if she minds if her mother is in the room with her.

The nurse is examining the testicles of a 6-year-old boy. How can the nurse prevent a retractile testis from slipping back up the inguinal canal? a) Apply gentle pressure on the inguinal canal. b) Place one finger over the inguinal canal. c) Ask the boy to stand. d) Ask the boy to sit cross-legged.

Ask the boy to sit cross-legged.

The nurse is assessing the growth of a premature infant. What would be the appropriate action by the nurse to complete this assessment? a) Weigh the infant's diapers. b) Plot the infant's weight, height, and length on a growth chart. c) Ask mom if her baby eats enough. d) Take vital signs.

Plot the infant's weight, height, and length on a growth chart

The nurse is collecting data on a 9-year-old child being admitted to the pediatric unit. Which of the following is the most appropriate way to gather information from the child's caregiver? a) Ask the caregiver if they can read or if they need someone to read the questions on the admission form to them. b) Have the child read the questions to the caregiver and then write down the answers on the form. c) Ask the caregiver questions and write the answers down. d) Have the caregiver sit in a quiet room and fill out a questionnaire.

Ask the caregiver questions and write the answers down.

A nurse is performing a physical examination on a newborn. Which of the following assessments should she include? a) Rectal temperature, femoral pulse, head circumference b) Oral temperature, blood pressure, head circumference c) Temporal temperature, blood pressure, reflexes d) Axillary temperature, femoral pulse, head circumference

Axillary temperature, femoral pulse, head circumference

The nurse is caring for a child who is on a cardiac monitor. Which of the following nursing actions would be the most important action for the nurse? a) Check the site and skin condition every couple of hours. b) Clean the skin with alcohol before placing the electrodes. c) Check to be sure that the electrodes are secure when the alarm sounds. d) Confirm the alarms are set with maximum and minimum settings.

Confirm the alarms are set with maximum and minimum settings.

The nurse is caring for a 13-year-old girl. As part of a routine health assessment the nurse needs to address areas relating to sexuality and substance use. Which statement should the nurse say first to encourage communication? a) Tell me about some of your current activities at school. b) Are you considering sexual activity? c) I promise not to tell your mother any of your responses. d) Do you smoke cigarettes or marijuana?

Tell me about some of your current activities at school.

A 6-month-old is admitted to the hospital because of a fever. When you obtain a health history, what data would you obtain first? a) History of past illnesses b) Details about the fever c) Family profile d) Review of systems

Details about the fever

During a routine physical examination of a 13 year old female the nurse notes the presence of a tender nodule just below the nipple on her right breast. Which action by the nurse is indicated? a) Request the teen have a breast ultrasound. b) Request the teen have a mammogram. c) Document the finding as normal. d) Review the teen's medical record for family history of breast cancer.

Document the finding as normal.

Where is the point of maximal impulse (PMI) found in Lucy who is 5 years old? a) The PMI is at the third intercostal space. b) The PMI is at the fourth intercostal space. c) The PMI is at the sternum. d) The PMI is at the clavicle.

The PMI is at the fourth intercostal space.

A nurse is conducting a physical examination on a 5-year-old boy and is examining his abdomen. First she visually inspects the region. Then she auscultates it with a stethoscope. Finally, she palpates the area. What is the proper rationale for performing the auscultation before palpation? a) Auscultation is scary for small children and should thus be performed first, to get it over with b) The order does not matter; she could have performed palpation before auscultation c) Handling the abdomen may obliterate bowel sounds d) If she detects no abnormalities in auscultation, there will be no need for palpation

Handling the abdomen may obliterate bowel sounds

Which statement indicates the best sequence for the nurse to conduct an assessment in a nonemergency situation? 1. Introduce yourself, ask about any problems, take a history, and do the physical examination. 2. Perform the physical examination and then ask the family if there are any problems in the child's life. 3. Do the physical examination while at the same time asking about the child's previous illnesses; then talk about the family's concerns. 4. Get a complete history of the family's health beliefs and practices, and then assess the child.

Introduce yourself, ask about any problems, take a history, and do the physical examination.

The nurse is taking a family history of a 10-year-old with asthma. What would be a helpful tool to obtain a family history of illness and disease? a) Have the family write down any history they remember. b) Help the family design a genogram. c) Have the family fill out a health questionnaire. d) Make a family tree for tracking purposes.

Help the family design a genogram.

Which of the following should a nurse include in her pediatric history of 8-year-old patient Rosie? a) Where Rosie lives b) How many friends Rosie has c) Immunizations d) Her favorite toys

Immunizations

Nurse Betty is beginning the examination of a 4-month-old infant. She takes the infant from the mother's arms to do the exam. Where should the nurse place the infant for the exam? a) In the nurse's own arms b) In the crib facing the mom c) In the crib on the infant's back d) In the child treatment room

In the crib facing the mom

Question: Below are the first six (of nine total) sections of an initial health assessment interview. Put them in the correct order: 1 Introduction and explanation 2 Chief concern/complaint 3 Demographic data 4 History of chief concern/complaint 5 Health and family profile 6 Day history

Introduction and explanation Demographic data Chief concern/complaint History of chief concern/complaint Health and family profile Day history

Nurse Julie is doing a physical exam on a 3-year-old boy. What method would Julie use to perform the exam? a) Julie would examine the child's head and work down to the child's toes. b) Julie would examine the child's chest and then go to the head and down. c) Julie would examine different sections of the body at various times. d) Julie would examine the child's extremities first and then the chest.

Julie would examine the child's head and work down to the child's toes.

A nurse is assessing an infant's reflexes. The nurse places his or her thumb to the ball of the infant's foot to elicit which reflex? a) Parachute b) Plantar grasp c) Palmar grasp d) Babinski

Plantar grasp

A nursing student asks the nursing instructor to explain pulse oximetry measurements in child. The nurse is accurate in telling the student: a) Pulse oximetry is done to detect respiratory retractions in the child. b) If the oximeter probe is to be left in place, the site should be checked every eight hours. c) Place the probe of the oximeter on the child's chest and secure it with tape. d) Pulse oximetry measures the oxygen saturation of arterial hemoglobin.

Pulse oximetry measures the oxygen saturation of arterial hemoglobin.

The nurse is performing an examination of the eyes of a 7-year-old girl. Which of the following findings would indicate that the third cranial nerve is intact? a) Light of an otoscope reflecting evenly off both pupils b) The eyelid blinks in response to touching the cornea with a wisp of cotton c) Pupil dilation in response to light d) Pupil constriction in response to light

Pupil constriction in response to light

The nurse is examining the genitals of a healthy newborn girl. The nurse should observe which normal finding? a) Lesions on the external genitalia b) Swollen labia minora c) Labial adhesions d) Swollen labia majora

Swollen labia minora

When performing a physical examination on a child, if there is a mirror image in shape, size, and position from one side of the body to the other, the child would have which of the following? a) Alignment b) Symmetry c) Retraction d) Accommodation

Symmetry

To obtain an accurate heart rate in an infant, which of the following would be the most important for the nurse to do? a) Take a radial pulse. b) Take the apical pulse. c) Count the pulse rate for 30 seconds. d) Use a regular stethoscope.

Take the apical pulse.

Which of the following is a grade II heart murmur? a) The murmur is soft but easily heard. b) The murmur is soft and hard to hear. c) The murmur is loud with an associated thrill. d) The murmur is loud without an associated thrill.

The murmur is soft but easily heard.

The nurse is collecting subjective data when doing which of the following? a) The nurse is weighing and measuring the child. b) The nurse is reinforcing teaching with the child's caregivers. c) The nurse is interviewing the child's caregiver. d) The nurse is taking the child's vital signs.

The nurse is interviewing the child's caregiver.

The nurse is weighing an 18-month-old infant who is in the clinic for a well-child visit. Which of the following actions by the nurse would be most appropriate for weighing this child? a) The nurse should lay the infant on the scale covered with a clean paper and gently hold the child flat against the scale and let go just before reading the weight. b) The nurse should weigh the mother on a standing scale and then weigh her again while the mother is holding the infant. c) The nurse should have the child sit on the scale while keeping a hand close to but not touching the child. d) The nurse should ask the mother to lightly hold the infant's hands while the infant is sitting on the scale.

The nurse should have the child sit on the scale while keeping a hand close to but not touching the child.

Where would the S2 "dub" sound be the loudest? a) The fifth intercostal space b) The fourth intercostal space c) The third intercostal space d) The second intercostal space

The second intercostal space

The nurse is doing an assessment of a 10-year-old girl. She whispers the girl's name from behind the girl. Which cranial nerve is the nurse assessing for? a) III b) VIII c) V d) IV

VIII