HA Module 10: Assessing newborns & infants; Assessing children & adolescents

13. The nurse is preparing to measure the head circumference of a newborn. In a healthy newborn, the nurse should expect the circumference of the infant's head to be within what range? A) 33 to 35.5 cm B) 35 to 37.5 cm C) 37 to 39.5 cm D) 39 to 41.5 cm

A) 33 to 35.5 cm

25. During the assessments of infants' genitalia, what finding most clearly warrants referral for further assessment? A) A newborn male has an undescended testicle. B) A newborn female has bloody vaginal discharge. C) A newborn female has engorged labia. D) A newborn male has intact foreskin.

A) A newborn male has an undescended testicle.

7. A 4-year-old boy is brought to the emergency department by his parents, who state that he has been crying and saying his ìtummy hurts.î Which method would be most appropriate for the nurse to initially assess the problem? A) Ask the child to point with one finger where it hurts. B) Inspect, palpate, percuss, and then auscultate the abdomen. C) Determine the time and character of the child's last bowel movement. D) Ask the child to describe the character of his pain.

A) Ask the child to point with one finger where it hurts.

11. The nurse assesses the respirations of a 2-week-old infant and identifies periods of apnea lasting longer than 20 seconds. What should the nurse do next? A) Assess the apical heart rate. B) Percuss the lungs for consolidation. C) Auscultate the lungs for adventitious sounds. D) Inspect the shape of the thorax.

A) Assess the apical heart rate.

23. The nurse's assessment of a child's hair reveals that it is clean and neatly trimmed but exceptionally dry and brittle. What is the nurse's best response to this finding? A) Assess the child for signs and symptoms of impaired nutrition. B) Assess the child for indications of abuse or neglect. C) Facilitate a referral to a dermatologist. D) Encourage the child's mother to ensure that the child gets adequate exposure to sunlight.

A) Assess the child for signs and symptoms of impaired nutrition.

30. A nurse is having difficulty getting a 14-year-old child to ìopen upî during the health interview. What strategy is most likely to enhance the nurse's communication with this child? A) Give the child some control over the course and content of the interview. B) Teach the child about the negative consequences of an inadequate interview. C) Arrange for one of the child's parents to speak with him or her privately. D) Promise the child a reward for participating in the interview.

A) Give the child some control over the course and content of the interview.

10. Which technique should the nurse use to perform scoliosis screening in a school-age child? A) Have the child bend forward at the waist. B) Measure the length of each of the child's legs. C) Measure the distance between the child's knees and ankles. D) Ask the child to walk across the room.

A) Have the child bend forward at the waist.

24. The nurse's inspection of a young child's anus reveals the presence of hemorrhoids. How should the nurse best interpret this assessment finding? A) Hemorrhoids are unusual in children and warrant further assessment. B) Hemorrhoids are a common indication of deficient fluid intake in children. C) Hemorrhoids are common in children until they attain bowel continence. D) Hemorrhoids in a child younger than 10 are suggestive of colorectal cancer.

A) Hemorrhoids are unusual in children and warrant further assessment.

17. The nurse is assessing a newborn's rooting reflex. What action should the nurse perform during this assessment? A) Touch the infant's lip or cheek with a gloved finger. B) Place a gloved finger in the newborn's mouth. C) Touch the ball of the newborn's foot. D) Hit the surface near where the newborn is lying.

A) Touch the infant's lip or cheek with a gloved finger.

2. A new mother asks the nurse, ìWhat are those small white spots on my baby's nose?î Which response by the nurse would be most appropriate? A) ìThose are small glands that look like whiteheads but will disappear soon.î B) ìThose white spots are lesions containing pus and are caused by a minor skin infection.î C) ìNewborns retain sweat, which causes those white bumps on their skin.î D) ìOften newborns have a rash of this type, which fades in a few days.î

A) ìThose are small glands that look like whiteheads but will disappear soon.î

9. Which child should the pediatric nurse suspect of having a developmental delay? A) A 5-month-old who does not sit unsupported B) An 11-month-old who does not pull himself to a standing position C) A 3-month-old who cannot grasp an object voluntarily D) A 12-month-old who cannot build a tower of eight blocks

B) An 11-month-old who does not pull himself to a standing position

9. A school nurse plans to test hearing acuity in students who range between kindergarten and sixth grade. Which of the following would be most appropriate method? A) Loud noise screening B) Audiometry C) Whisper test D) Weber test

B) Audiometry

2. When assessing adolescent girls, the nurse should know that which of the following usually appears first? A) Pubic hair B) Breast buds C) Axillary hair D) Menses onset

B) Breast buds

17. The nurse assesses the respiratory rate of a 5-year-old boy. Which finding would indicate to the nurse that his rate is within the age-appropriate range for this child? A) 16 breaths/minute B) 24 breaths/minute C) 32 breaths/minute D) 40 breaths/minute

B) 24 breaths/minute

26. The nurse is assessing a 6-year-old child. While auscultating the child's apical heart rate, the nurse notes that the child's heart rate increases during inspiration. What is the nurse's most appropriate action? A) Arrange for a STAT electrocardiogram. B) Document this as an expected assessment finding. C) Facilitate a referral for medical assessment. D) Reposition the child and then reassess.

B) Document this as an expected assessment finding.

12. The nurse is assessing the skin of a 12-hour-old infant. Which assessment finding would be cause for concern? A) Milia B) Jaundice C) Erythema toxicum D) Mongolian

B) Jaundice

26. The nurse is completing a head-to-toe assessment of a newborn infant. How should the nurse determine if the infant's anus is patent? A) Spread the infant's buttocks to facilitate inspection. B) Observe for the passage of meconium. C) Insert a gloved finger 0.5 to 1 cm into the rectum. D) Auscultate for bowel sounds to all four abdominal quadrants.

B) Observe for the passage of meconium.

15. When the nurse palpates the abdomen of a preschool boy, he begins to giggle and draw his legs up onto his abdomen. Which of the following would be most appropriate for the nurse to do? A) Omit the entire abdominal exam. B) Palpate with the child's hand under the nurse's hand. C) Ask the parent to discipline the child. D) Explain the purpose of the exam to the child.

B) Palpate with the child's hand under the nurse's hand.

20. After inspecting an adolescent male's genitalia, the nurse documents the findings as Tanner stage 3. Which of the following findings would be most likely? A) Scrotum and testes slightly enlarged; sparse, long, downy pubic hair B) Penis elongated; pubic hair sparse over pubis, coarse and curly C) Penis increased in width; abundant pubic hair not extending to thighs D) Penis of adult size; dark curly abundant pubic hair to thighs

B) Penis elongated; pubic hair sparse over pubis, coarse and curly

14. A nurse is reviewing an infant's Apgar score. Which of the following areas was assessed during the calculation of the score? A) Temperature B) Reflex irritability C) Head circumference D) Weight

B) Reflex irritability

22. The nurse has assessed the head circumference (HC) of an 18-month-old during a regular checkup. The nurse should compare the percentile of the child's HC to which of the following? A) The child's body mass index B) The child's height and weight percentiles C) The child's chest circumference percentile D) The child's developmental stage

B) The child's height and weight percentiles

1. A preadolescent girl comes to the clinic for a sports physical exam. The nurse notes beginning breast development and documents which of the following? A) Gynecomastia B) Thelarche C) Menarche D) Adolescence

B) Thelarche

24. A new mother rings her call bell after giving birth to a healthy infant 18 hours earlier. The client states that her infant ìlooks like she has milk coming out of her nipples.î How should the nurse best interpret this phenomenon? A) The infant is showing signs of postnatal mastitis. B) This is a normal finding that results from hormonal stimulation. C) This is an expected finding in female infants but an unexpected finding in male infants. D) The nurse should plan to manually express the liquid from the infant's breasts.

B) This is a normal finding that results from hormonal stimulation.

18. A nurse is assessing a 9-month-old infant. Which reflexes would the nurse expect to assess? Select all that apply. A) Rooting B) Sucking C) Tonic neck D) Moro E) Palmar grasp F) Babinski

B, F

10. A nurse is presenting a class for new parents about infant care. To decrease the risk of sudden infant death syndrome, the nurse should encourage parents to place their sleeping infants in what position? A) Prone B) Supine C) High Fowler's D) Low Fowler's

B. Supine

21. A clinic nurse is assessing a 6-month-old infant prior to the administration of scheduled immunizations. The nurse should anticipate that the infant's resting heart rate will be nearest to what value? A) 80 beats per minute B) 100 beats per minute C) 120 beats per minute D) 140 beats per minute

C) 120 beats per minute

12. A mother voices concern about the amount of time her school-age child sleeps. When responding to the mother, the nurse understands that this age group sleeps an average of how many hours each night? A) 11 to 12 B) 9 to 10 C) 8 to 9.5 D) 7 to 8

C) 8 to 9.5

15. The nurse is preparing to measure the chest circumference of a 2-day-old newborn. The nurse would place the tape measure at which area? A) High up under the axillary area B) At the level of the umbilicus C) At the level of the nipple line D) Midway between the nipple line and umbilicus

C) At the level of the nipple line

29. The nurse is auscultating the bowels of an infant who was born 10 hours ago. What principle should guide the nurse's assessment and data analysis? A) Bowel sounds are not normally audible until 48 to 72 hours postpartum. B) Bowel sounds are not normally audible until 24 to 48 hours postpartum. C) Bowel sounds should be audible every 10 to 30 seconds. D) Bowel sounds should be absent at rest and audible after palpation

C) Bowel sounds should be audible every 10 to 30 seconds.

18. A nurse is providing an in-service presentation to a group of new pediatric nurses and reviewing differences in assessment of children and adults. When describing the heart sound typically auscultated in children in comparison to an adult, which characteristic would the nurse describe? A) Children typically have softer heart sounds. B) Children typically have less harsh heart sounds. C) Children typically have higher pitched heart sounds. D) Children typically have heart sounds of longer duration.

C) Children typically have higher pitched heart sounds.

30. In preparation for discharge, the nurse is assessing a newborn infant's hearing acuity. How should the nurse best perform this assessment? A) Determine whether the infant turns his or her head toward verbal stimuli. B) Determine whether the infant makes eye contact in response to a loud voice. C) Determine whether a loud noise near the infant evokes a startle response. D) Determine whether the infant appears to recognize the mother's voice.

C) Determine whether a loud noise near the infant evokes a startle response.

6. The nurse has identified a need to discuss sexuality with a 15-year-old client. How should the nurse best plan this aspect of the health interview? A) Obtain informed consent for the health interview. B) Begin by explaining appropriate and acceptable sexual behavior. C) Discuss the matter when a parent is not present. D) Ensure that a chaperone is in the room during the interview.

C) Discuss the matter when a parent is not present.

23. The nurse is assessing a newborn infant who currently has nasal congestion and rhinorrhea (runny nose). When analyzing these data, the nurse should consider which of the following? A) Nasal congestion in an infant is indicative of infection. B) Nasal mucus in infants should be treated with an inhaled vasoconstrictor. C) Nasal congestion can impair oxygenation because infants are nose breathers. D) Nasal congestion in infants is an expected finding for the first 6 weeks of life.

C) Nasal congestion can impair oxygenation because infants are nose breathers.

19. A nurse has completed an assessment of a school-age child. The nurse has identified several ìsoft signsî of potential neurologic impairment. How should the nurse best interpret these findings? A) Recognize that the findings are related to developmental tasks rather than neurologic pathology B) Recognize the need for an emergency neurological assessment C) Recognize that the findings may or may not indicate the presence of a neurologic problem D) Recognize that the findings need to be interpreting in light of the child's education level

C) Recognize that the findings may or may not indicate the presence of a neurologic problem

27. The nurse is performing Ortolani's maneuver to test for congenital hip dysplasia in a newborn infant. What finding would suggest the presence of hip dysplasia? A) The infant expresses no signs of pain or discomfort during manipulation of the hip. B) The nurse is unable to perform passive range of motion of the infant's hip joint. C) The nurse hears a click from the site of the infant's hip joint. D) The nurse is unable to bring the infant's knees into alignment.

C) The nurse hears a click from the site of the infant's hip joint.

13. The nurse is teaching a group of parents of children of various ages how to best measure a child's temperature. The nurse instructs the parents that rectal temperature measurement is indicated in which situation? A) During the newborn period B) When a child is dehydrated C) When no other route is feasible D) When rapid temperature changes occur

C) When no other route is feasible

21. The pediatric nurse is obtaining the nursing history of a 4-year-old girl who is accompanied by her mother. What question should the nurse pose to the child's mother? A) ìIs your daughter able to pick out her name from a page of writing?î B) ìDo you think your daughter can see others' points of view?î C) ìDoes your daughter often ask 'why'?î D) ìDoes your daughter like to collect things?î

C) ìDoes your daughter often ask 'why'?î

6. A nurse assesses the pulses of an infant and notes that the femoral pulses are weak. Which of the following health problems should the nurse suspect? A) Right ventricular enlargement B) Sinus arrhythmia C) Coarctation of the aorta D) Patent ductus arteriosus

C. Coarctation of the aorta

25. The nurse inspects a 10-day-old infant's umbilicus and notes that it is reddened with the presence of slight discharge. What nursing diagnosis is suggested by these data? A) Risk for contamination B) Ineffective peripheral tissue perfusion C) Infection D) Risk for injury

C. Infection

8. A nurse is conducting a workshop with a group of adults who are enrolled in a parenting class. Which of the following would the nurse emphasize as important in helping the school-age child achieve the psychosocial task of industry and avoid inferiority? A) Allow independence B) Encourage competition C) Increase socialization D) Acknowledge accomplishments

D) Acknowledge accomplishments

16. The nurse is assessing a newborn's neuromuscular maturity in light of the infant's known gestational age. Which of the following would the nurse expect to find if the newborn was premature? A) Flexed arms and legs B) Elbow position less than midline C) Heel distant from ear D) Delayed arm recoil

D) Delayed arm recoil

27. The school nurse is assessing a 15-year-old client. The nurse should understand that this child's current priorities will most likely reflect what developmental task? A) Exerting influence B) Learning new information C) Becoming productive D) Developing a personal identity

D) Developing a personal identity

29. The nurse is experiencing challenges in eliciting information during the health interview of a 4-year-old boy. How can the nurse best foster communication with the child? A) Set a time limit for completing the interview. B) Ask the child to talk about himself in the third person. C) Explain the purpose of the interview in simple terms. D) Engage the child in play.

D) Engage the child in play.

4. The nurse is assessing the anterior fontanelle of a 4-month-old infant brought to the clinic for a well-child exam. Which of the following would the nurse expect to assess? A) Sunken fontanelles B) Closed fontanelles C) Bulging fontanelles D) Flat fontanelles

D) Flat fontanelles

28. The nurse is meeting the parents of an ill child for the first time and is preparing to perform the health interview. In addition to gathering health data, what additional goal should the nurse prioritize during this interaction? A) Gauge the parents' own levels of health. B) Emphasize the importance of adherence to treatment. C) Identify the family's socioeconomic status. D) Foster trust with the child's parents.

D) Foster trust with the child's parents.

19. When the nurse palpates the neck of an infant, he notes the presence of crepitus at the right shoulder area. The infant also exhibits decreased movement in the right arm. Which of the following should the nurse suspect? A) Osteomyelitis B) Down syndrome C) Fractured humerus D) Fractured clavicle

D) Fractured clavicle

1. When assessing a newborn, the nurse observes that the infant's hands and feet are bluish in color. The nurse interprets this finding as being suggestive of which of the following? A) Cardiopulmonary dysfunction B) Peripheral vascular disease C) Acid base imbalance D) Ineffective temperature regulation

D) Ineffective temperature regulation

5. The nurse is performing an otoscopic examination of an infant's ears. Which of the following actions should the nurse do? A) Pull the pinna forward and down. B) Pull the pinna up and back. C) Pull the pinna straight back. D) Pull the pinna down and back.

D) Pull the pinna down and back.

4. Which finding would require further evaluation or referral when auscultating heart sounds on an 8-year-old client during a routine physical exam? A) Audible S3 B) Soft systolic murmur C) Sinus arrhythmia D) Pulse rate 120 beats per minute

D) Pulse rate 120 beats per minute

28. The nurse's assessment of an infant reveals a positive Barlow's sign. What collaborative problem should the nurse consequently identify? A) RC: Failure to thrive B) RC: Jaundice C) RC: Patent ductus arteriosus D) RC: Hip displacement

D) RC: Hip displacement

7. Which action would be most appropriate when a nurse assesses the umbilical cord of a 4-day-old infant and finds it to be dried and black? A) Notify the newborn's physician. B) Apply warm compresses. C) Apply an antibiotic ointment. D) Recognize this as normal.

D) Recognize this as normal.

14. During a well-child visit, a parent asks the nurse the best way to manage negativism in her toddler. Which suggestions by the nurse would be most appropriate? A) Implement punishment appropriate for the child's age. B) Spend more quality time with the child. C) Repeatedly tell the child not to always say 'no.' D) Reduce the opportunities for a ìnoî answer.

D) Reduce the opportunities for a 'no' answer.

22. The nurse is assessing a 2-day-old infant prior to discharge home from the hospital with his mother. When assessing the infant's eyes, what finding would the nurse consider to be abnormal? A) The infant is unable to follow a moving object or light. B) The infant's periorbital area is slightly edematous. C) The infant's pupils react to light. D) The infant's sclerae have a yellowish tint.

D) The infant's sclerae have a yellowish tint.

5. During palpation of a young child's abdomen, the nurse assesses the liver. Which of the following would the nurse expect to find? A) The liver can be palpated 4 cm below the right costal margin. B) The liver is not palpable. C) The liver is found at the left costal margin. D) The liver is located 2 cm below the right costal margin.

D) The liver is located 2 cm below the right costal margin.

8. A parent of an ill infant states, ìWe've gave him ibuprofen for a fever, and he had an allergic reaction.î Which response would be most appropriate? A) ìIs he allergic to any other drugs?î B) ìI will write that on his chart so he won't be given any.î C) ìHow often has he received ibuprofen?î D) ìDescribe what happens to him when he takes ibuprofen.î

D) ìDescribe what happens to him when he takes ibuprofen.î

3. When describing cultural differences related to tooth eruption, the nurse explains that permanent teeth typically appear earlier in which group? A) Caucasians B) Hispanics C) African Americans D) Native Americans

c. African Americans

3. The nurse completes the initial newborn assessment and notes the presence of fine, downy hair on the infant's shoulders and back. The nurse documents the presence of which of the following? A) Vernix B) Milia C) Lanugo D) Nevi

c. Lanugo

20. While assessing an infant's abdomen, which finding would the nurse interpret as necessitating immediate evaluation and treatment? A) Palpable mass B) Tenderness C) Rigidity D) Gurgling sounds

c. rigidity

16. The nurse is participating in a vision-screening program for children age 3 to 10 years. The nurse would expect a child to have 20/20 vision at what age? A) 3 to 4 B) 4 to 5 C) 5 to 6 D) 6 to 7

d. 6-7

11. During the health history, a nurse asks a mother to describe the play activities of her school-age son. The mother reports activities that are typical for this age group. The nurse would document this as which type of play? A) Imitative B) Associative C) Parallel D) Competitive

d. competitive