PrepUs for Pediatrics Chapter 28

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 reccomendations 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 congential 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.

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.

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 questions 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.

The nurse is completing intial health assessments for clients being admitted to the acute care facility. Below are the first six (of nine total) sections of an initial health assessment interview. In which order would the nurse complete the documentation?

Introduction and explanation Demographic data Chief concern/complaint History of chief concern/complaint Health and family profile Day history Data gathering for an initial health assessment can be divided into nine sections in the following order: 1) introduction and explanation; 2) demographic data; 3) chief concern; 4) history of chief concern; 5) health and family profile; 6) day history; 7) past health history, including pregnancy history; 8) family health history; 9) review of systems.

The nurse is performing an examination of the eyes of a 7-year-old girl. 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.

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.

During an assessment, a child exhibits an audible high-pitched inspiratory noise, a tripod stance and intercostal retractions. Using SBAR communication, the nurse notifies the health care provider and states which breath sounds that are congruent with the clinical presentation of the child?

Respiratory stridor Stridor is a high-pitched, readily audible inspiration noise that indicates an upper airway obstruction. The child presents in severe respiratory compromise and struggles to breathe. A wheeze is a high-pitched sound heard on auscultation, usually on expiration. It is due to obstruction in the lower trachea or bronchioles. Rales are crackling sounds heard on auscultation when the alveoli become fluid filled. Rhonchi is a snoring sound heard throughout the lung field when inflammation occurs.

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

An 18-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 nurse is wrapping up a health interview with the parent of a toddler. Which would be the best question or statement to end the interview?

"Is there anything more about your child that we should know?"

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.

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.

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 futher 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.

The nurse is preparing to assess the abdomen of a preschool-aged child. Which technique should the nurse use first?

Inspection To assess an abdomen, first inspect the surface for symmetry and contour. After inspection, the nurse should auscultate for bowel sounds. The examination concludes with percussion and palpation.

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.

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.

The nurse is listening to the breath sounds of a 4-year-old child. Which sound should the nurse determine as being normal for this client?

Rhonchi Rhonchi are snoring sounds that are made by air moving through mucus in the bronchi. This is a normal sound. Stridor is a crowing sound being made through a constricted larynx. This is an abnormal sound. Crackles are sounds made by air moving through fluid. This is an abnormal sound. Wheezing is a whistling sound made by air moving through a narrow bronchus. This is an abnormal sound.

Which finding would the nurse interpret as least significant when assessing a child's lungs?

Rhonchi Rhonchi is the sound of air passing over mucus in the airway. Stridor and wheezing denote a constricted airway. Crackles denote fluid in alveoli, which is the mark of pneumonia.

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

Martha has her 5-year-old child at the clinic for a checkup. When reviewing the child's history, which of the following would the nurse identify as a primary preventive measure?

The last immunizations the child obtained Immunizations are an example of primary prevention. Other examples of primary prevention include chlorination and fluoridation of water, applying dental sealants to prevent tooth decay, and anticipatory guidance given to parents and family members of young children about the need to keep chemicals out of their child's reach.

The health care provider has prescribed a rectal temperature for an 11-month-old infant. The thermometer has been lubricated with a water-soluble lubricant. How far into the rectum would the nurse insert the thermometer?

1/4 to 1/2 inch (0.64 to 1.27 cm) The correct distance to insert a rectal thermometer is 1/4 to 1/2 inch (0.64 to 1.27 cm). One-eighth to one-fourth inch (0.32 to 0.64 cm) may not be far enough and further than 1/2 inch (1.27 cm) is too far.

The nurse is measuring the head circumference of a newborn during a well-child visit. Until which age should the nurse take this measurement?

24 months Head circumference is measured at every visit until the child is 2 years of age.

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

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

The nurse is collecting data on a 9-year-old child being admitted to the pediatric unit. What is the most appropriate way to gather information from the child's caregiver?

Ask the caregiver questions and document the answers. The family caregiver provides most of the information needed in caring for the child, especially the infant or toddler. Rather than simply asking the caregiver to fill out a form, it may be helpful to ask the questions and write down the answers. This provides a personal interaction between the nurse and the caregiver. If the caregiver can not read then the nurse would help with the completion of the form by asking questions and documenting the answers. Children should not be used as interpreters or complete a form. If the child is under the age of 18 it would not be a legal document and with a child's language skills and comprehension much needed information could be not obtained.

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.

The nurse prepares to perform a head-to-toe exam on an infant. Which nursing action will the nurse perform?

Count the infant's respirations for a full minute Because the infant has an irregular respiratory pattern and rate, the nurse must count the infant's respirations for a full minute. A child should have an oral temperature recorded, as it is more accurate than an axillary temperature. Palpating and counting the brachial pulse in an infant is not the most accurate way to assess the infant's heart rate. It is not necessary for the nurse to listen to the infant's bowel sounds in each quadrant for one full minute

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

The nurse is preparing to assess a school-age child who is experiencing pain in the left femur area. When conducting this assessment, at which point should the nurse assess the painful region?

Last If a child has a sensitive or painful body part, palpate that area last. Otherwise, the child may be unwilling to allow other parts to be touched in fear of additional pain. The painful regions should not be assessed first, after measuring vital signs, or before the abdominal assessment.

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.

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 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.

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 nonstretching 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 depict incorrect placement of the tape for measurement and would not provide a correct measurement of the head.

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 database?

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 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 their 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 is preparing to measure the head circumference of a 6-month-old child. How should the nurse make this measurement?

Above the eyebrows through the prominent part of the occiput Head circumference is measured by placing a tape measure around an infant's head just above the eyebrows and around the most prominent portion of the back of the head or the occipital prominence. Head circumference is not measured using the hairline or the forehead.

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 preschoolers, and warmly shaking the hand of older children and teens 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 which will be used.

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 conducting a physical examination of a child following a comprehensive health history. What should be the focus of the physical examination?

Chief complaint The next step after the health history is the physical examination. It should focus on the chief complaint or any of the systems that engaged the nurse's critical thinking while obtaining the history. The child and parents are involved in the assessment but the focus is on the health problem. The nurse should conduct a physical examination with the child's developmental age in mind.

The nurse is preparing to assess the respiratory rate of a crying 15-month-old boy. To get the most accurate assessment, what approach should the nurse take?

Count after the child stops crying and is comfortable. Respirations should be assessed when the child is resting or sitting quietly because respiratory rate changes significantly when children cry, eat, or become more active. They also breathe more rapidly when anxious or frightened. Counting respirations for a full minute assures accuracy. Infants' respirations are primarily diaphragmatic; therefore, counting abdominal movements promotes accuracy. Placing a stethoscope to count respirations tends to be seen as invasive by a toddler and will result in movement away or an increase in respirations.

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 nurse assesses a 16-year-old and notes no nasal hair. What would the nurse do first?

Determine if the client uses illegal drugs. Adolescents who sniff cocaine lose nasal hair and may have excoriations or abscesses in the mucous membrane as well as holes in the septum. Smoking and ingesting drugs will not cause the same effect as sniffing. Huffing refers to inhalation via the mouth. It's important to determine if the client has been burned previously, and obtaining the client's history is important data to collect, but this would not be specific information needed if drug use was suspected.

When percussing the chest of an infant the nurse hears hyperresonant sounds. What action should the nurse take?

Document the finding. Percussion of the lung sounds reveal resonance in older children. The sound will be hyperresonant in infants and younger children due to the thinness of the chest wall. Over expanded lungs will sound hyperresonant in older children. Lungs filled with fluid sound dull in older children and less resonant in younger children. Because these are normal findings in an infant documentation is the only necessary step the nurse should take.

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 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.

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.