CH 29 - The Complete Physical Assessment: Infant, Young Children

At which age in years would a positive Babinski reflex in a child be a normal finding? 1 3 5 7

1 It is normal for a 1-year-old child to have a positive Babinski reflex. A Babinski reflex usually disappears by 24 months of age (2 years old). Therefore a child 3, 5, or 7 years old with a positive Babinski would be abnormal.

At which time would the nurse perform the initial Apgar test in a newborn? 1 minute after birth 5 minutes after birth First well-baby check Third well-baby check

1 minute after birth The initial Apgar test is performed 1 minute after birth. The nurse assesses the neonate by using the Apgar scoring system 1 minute after birth and then again 5 minutes after birth. The Apgar score provides important data on the neonate's immediate response to extrauterine life. The first and third well-baby checks are too late to perform the Apgar test.

The nurse pulls the infant's arm across its chest and finds that the infant's elbow does not cross the midline. How would the nurse report this finding? Absence of the scarf sign Presence of the Moro reflex Absence of the Ortolani sign Presence of the Babinski reflex

Absence of the scarf sign The nurse would report absence of the scarf sign. If an infant's elbow does not cross its midline, which it should not, then it indicates that the infant lacks the scarf sign. The scarf sign helps determine muscle tone. If the infant cries or demonstrates a startle response when hearing a loud noise, then it indicates the presence of a Moro reflex. The Ortolani test helps determine if the infant has a hip dislocation. Absence of a clunk on flexing the hips and knees indicates absence of the Ortolani sign in the infant. If the infant fans the toes after receiving a gentle stroke on the foot, it indicates the presence of a Babinski reflex.

Which technique would the nurse use to assess patency of the anus in a 1-day-old neonate? Check the trunk incurvation reflex. Inspect symmetry of gluteal folds. Inspect for tufts of hair. Check for the passage of meconium.

Check for the passage of meconium. The nurse would check for the passage of meconium in a neonate within 24 to 48 hours to assess the patency of the anus. The trunk incurvation reflex helps determine spinal cord and nerve functioning. Symmetry of gluteal folds helps determine hip abnormalities, not patency of the anus. Inspection for tufts of hair determines abnormal formation; it does not assess patency of the anus.

Which intervention would the nurse incorporate to assess a child's cardinal positions of gaze? Cover the eye with an index card or thumb. Direct a moving penlight in front of the eye. Inspect the fundus with an ophthalmoscope. Elicit the blink reflex with the help of a penlight.

Direct a moving penlight in front of the eye. A moving penlight is directed in front of the eye to assess the cardinal positions of gaze. The nurse assesses a child's eye by covering it with an index card or thumb while performing the cover test. An ophthalmoscope is not used to assess the cardinal positions of gaze. It is used to elicit the red reflex and inspect the fundus. The cardinal positions of gaze do not include assessment of the blink reflex with the help of a penlight.

Which reflex would the nurse be testing by slowly rotating the newborn from side to side? Grasp Rooting Babinski Doll's eye

Doll's eye While testing the doll's eye reflex, the nurse turns the newborn slowly from side to side and observes the eye movements. The doll's eye reflex helps determine neuromuscular functioning in a newborn. The grasp reflex is tested when the nurse places an object in the newborn's palm and determines the newborn's ability to grasp and curl the fingers. The rooting reflex is tested by the nurse gently stroking the newborn's cheeks with a finger and observing whether the newborn turns its head to suck. To test the Babinski reflex in the newborn, the nurse gently strokes the outer side of the sole of the newborn's foot.

Which assessment would help the nurse evaluate an infant's upper extremities? Eliciting patellar reflexes Evaluating for the scarf sign Assessing for the Ortolani sign Testing the reflex of the biceps

Evaluating for the scarf sign The nurse examines an infant for the absence of the scarf sign during an assessment of the upper extremities. When the nurse manipulates the arms, the elbows should not reach the infant's midline. The nurse uses the reflex hammer to elicit patellar reflexes while examining the lower extremities of a young child, not an infant. The lower extremities of an infant are assessed for the Ortolani sign to evaluate the stability of the hip. The nurse uses a reflex hammer to test the reflex of the biceps in a young child. This test is not used to assess an infant's upper extremities.

Which reflex would the nurse observe when a newborn starts to cry and extends the legs, arms, and fingers when there is a loud noise? Grasp Startle Triceps Babinski

Startle The startle reflex is triggered by a loud noise, which causes the newborn to cry and extend the arms and legs. If the newborn holds the nurse's finger after the nurse firmly places it on the newborn's palm, then it indicates the newborn has a grasp reflex. If the newborn stretches his or her leg when the nurse taps the triceps tendon with a reflex hammer, it indicates the newborn has a triceps reflex. If the newborn turns the foot and flares the toes after the nurse applies a gentle stroke on the outer side of the newborn's sole, it indicates the newborn has a Babinski reflex.

Which action would the nurse take when performing a physical assessment on a young child? Use an otoscope to assess the red reflex in the child. Auscultate breath sounds on one side of the chest for adventitious sounds. Inspect the chest for pulsations on the precordium. Have the child remove his or her underpants at the beginning of the examination.

Inspect the chest for pulsations on the precordium. The nurse would inspect the chest for pulsations on the precordium to determine cardiac functioning. An otoscopic examination helps the nurse inspect the inner ear canal and tympanic membrane. The red reflex is an ophthalmic condition that can be tested by using an ophthalmoscope. Therefore the nurse would perform an ophthalmic examination to assess the red reflex. The nurse auscultates breath sounds on both sides of the chest for adventitious sounds. The nurse would compare the lung sounds on both sides. A young child will not be self-conscious and may not hesitate to undress in front of a stranger. Therefore the nurse would have the child remove the underpants during the genital examination, not at the beginning of the examination.

Which assessment would the nurse perform last during an infant examination? Inspecting the tympanic membranes Assessing the infant for the stepping reflex Examining the symmetry of the gluteal folds Inspecting the trunk for the incurvation reflex

Inspecting the tympanic membranes The nurse uses an otoscope to inspect an infant's tympanic membranes. This is a slightly invasive procedure and, therefore, done last during the physical examination. The stepping reflex is assessed during the neuromuscular examination by holding the infant upright and allowing the infant's feet to touch the examination table. The nurse inspects the symmetry of the gluteal folds and the trunk for the incurvation reflex during the examination of the spine and the rectum. The nurse assesses the spine and rectum before the otoscopic examination.

Which organ would the nurse be able to feel when performing deep palpation of the infant's abdomen? Liver Spleen Kidney Bladder

Kidney The kidneys are located deep inside the abdomen, so the nurse would deeply palpate the infant's abdomen. The liver, spleen, and bladder require only light palpation for assessment.

Which parameter would the nurse be assessing for when using the Denver II test? Motor skills Skin integrity Hip displacement Genital development

Motor skills The nurse assesses motor skills by observing gait, jumping, hopping, standing on one foot, building a tower, and throwing a ball. The Denver II is a developmental screening test that helps assess motor and cognitive development in a preschooler or a school-age child. The Denver II test does not help determine the presence of skin integrity in the child. This would be done by directly observing the skin for any lesions. Hip displacement can be evaluated by assessing the Ortolani sign. During the Denver II test, the nurse does not evaluate the orientation of the femur in the acetabulum and does not assess the Ortolani sign. To evaluate genital development, the nurse would inspect the external genitalia of the child, but would not perform the Denver II test.

Which action would the nurse take to elicit the tonic neck reflex in an infant? Turn the infant's head and observe the eye movements. Place the infant in a supine position on an examination table during the test. Insert a gloved little finger into the infant's mouth while the infant lies on the examination table. Hold the infant upright and place the infant's foot on the examination table.

Place the infant in a supine position on an examination table during the test. The tonic neck reflex is tested by placing the infant in a supine position. While testing the doll's eye reflex, the nurse would turn the infant's head and observe eye movements. While assessing the sucking reflex, the nurse would insert a gloved little finger into the infant's mouth. While assessing the stepping reflex, the nurse would hold the infant in an upright position and place the infant's foot on the table.

Which vital signs would the nurse generally take while assessing a healthy neonate? Select all that apply. Pain Pulse Respiration Temperature Blood pressure

Pulse Respiration Temperature The regular assessment of vital signs in a healthy neonate includes the measurement of the pulse, respiration, and temperature. The nurse does not generally assess pain, which is often absent in the healthy neonate. Blood pressure is not usually measured in a neonate.

Which body part would the nurse assess to examine the trunk incurvation reflex in an infant? Abdomen Lower limbs Anal opening Spinal column

Spinal column The spinal column would be assessed to determine trunk incurvation reflex. The nurse examines the umbilicus, hernia, skin turgor, muscle tone, organs, pulses, lymph nodes, and bowel sounds in an abdominal assessment. The abdominal examination cannot assess the trunk incurvation reflex. To assess the development of the lower limbs, the nurse would note the range of motion and muscle tone and test for the presence of the Ortolani sign in the newborn. The nurse would inspect the anal opening for patency, not for the trunk incurvation reflex.

Which intervention would the nurse incorporate to open the eyes of a neonate for an examination? Place the neonate in a supine position on the examination table. Ask the parent to hold the neonate while the head is tilted sideways. Support the head and shoulders and gently lower the neonate backward. Lift the neonate under the axillae, hold, and face the neonate at eye level.

Support the head and shoulders and gently lower the neonate backward. The nurse supports the neonate's head and shoulders and gently lowers the neonate backward to open his or her eyes for an examination. Placing the neonate in a supine position on the examination table will not help open the eyes. The parent may hold the neonate over the shoulder while the nurse stands behind the parent to examine the eyes. Tilting the neonate's head sideways, however, may not help the nurse examine the eyes. The nurse lifts an infant under the axillae, holds, and faces the infant at eye level to note the shoulder tone and the infant's ability to stay in the nurse's hands without slipping.

The nurse lifts the infant by supporting the shoulders and lets the infant's head drop back for which purpose? To examine the neck To test the Babinski reflex To test for the Moro reflex To look at auricle alignment

To examine the neck This technique would allow the nurse to examine the neck. The nurse determines the symmetry of the neck and functioning of the neck muscles by supporting the shoulders and letting the head drop back. To check the Babinski reflex, the nurse would gently stroke the sole of the infant's foot. The nurse can test the Moro reflex by making a loud noise or jarring the infant's crib. To inspect auricle alignment, the nurse would examine the infant's ears by placing him or her in the supine position.