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The nurse is preparing to assess the heart sounds in a 3-year-old child. To locate the apical impulse, the nurse should plan to place the stethoscope at the child's third intercostal space. fourth intercostal space. second intercostal space. fifth intercostal space.

fourth intercostal space. Explanation: The apical impulse is felt at the fourth intercostal space left of the mid-clavicular line in young children.

While attempting to auscultate heart sounds a 2-year old client pushes the nurse's hand away. What should be done to facilitate this assessment? hold the arms down until the child calms down give the child something to hold in each hand ask the mother to hold the child's arms give the child a pacifier

give the child something to hold in each hand Explanation: If 2-year-olds are holding something in each hand it is more difficult for them to fight or resist. A pacifier would not be appropriate for this child. Holding the arms down could cause the child to become more agitated.

The nurse is preparing to assess the gross motor development of a 4-year-old child. The nurse should ask the child to hop on one foot. throw a ball. skip a rope. balance on alternate feet with eyes closed.

hop on one foot. Explanation: Four-year-old children can skip, hop on one foot, catch a ball, and go downstairs using alternate feet.

During the health assessment interview, which question should the nurse ask the parents of a preschooler to determine the child's level of motor development? "Can your child spontaneously scribble?" "Can your child jump with both feet?" "Can your child run, hop, and skip?" "Can your child walk up and down steps?"

"Can your child run, hop, and skip?" Explanation: The most appropriate question for the parents of a preschooler would be to ask if the child can run, hop, and skip. Running, hopping, and skipping indicate the level of motor development in the child. The nurse need not ask the parents if the child can scribble, because at 15 months the child can spontaneously scribble. Parents of a toddler should be asked if their child can walk up and down the steps and jump with both feet.

What question should the nurse ask in order to assess an adolescent's risk factors for obesity and deficient nutritional status? "Have you learned to cook yet?" "What do you eat in a typical day?" "What are your three favorite foods or drinks?" "Do you ever feel fat or think of yourself as being overweight?"

"What do you eat in a typical day?" Explanation: Describe what you eat on an average day. Overweight and obesity have serious health consequences among children and adolescents, including a greater risk of high cholesterol, hypertension, and diabetes mellitus.

The parent of a 2 year old is concerned her child is talking but she cannot understand her. The nurse explains that this should occur by what age? 2 3 4 5

3 Explanation: A 4-year-old child is generally talkative and engaged in the visit and can answer simple questions about self and concerns . Listen for speech difficulties. By 2 years of age, the child uses two-word sentences; by 3 years of age, a child should speak in more complicated sentences with speech that is understandable 75% or more of the time.

During the developmental evaluation, the nurse should utilize the Denver Developmental Screening Test II for which age child? 5 year old 7 year old 9 year old 11 year old

5 year old Explanation: The Denver Developmental Screening Test II (DDST-II) (Frankenburg, Dodds, Archer, Shapiro, & Bresnick, 1992) is one of several standardized developmental screening tests used in the examination of the child and required for early and periodic screening and developmental testing. The DDST-II is considered the standard criterion for the developmental evaluation of children aged 1 month to 6 years. It evaluates four developmental areas of interest: personal/social, language, fi ne motor/adaptive, and gross motor.

After the age of 2 years, how much do toddlers grow per year? About 3 cm About 5 cm About 7 cm About 9 cm

About 5 cm Explanation: After 2 years, toddlers gain about 2 to 3 kg and grow 5 cm per year.

A nurse recognizes that a most valuable communication tool when working with small children is what technique? Actively engage in play Maintain eye contact at all times Explain procedures thoroughly Proceed quickly to avoid stress

Actively engage in play Explanation: Play is one of the most valuable communication techniques when working with small children. It allows the nurse to discover important cues to the child's development and illness behaviors. Eye contact is often seen as intrusive in some cultures and the nurse should be sensitive to this. Small children need to be given age appropriate instructions. Rushing the interview may cause stress in some children and the nurse should take the tie to listen and allow the child to feel comfortable during the interview.

A young child refuses to allow a nurse to palpate the abdomen because it tickles. How can the nurse decrease the child's ticklishness to facilitate completion of the exam?

Allow the child to place the hand under the examiner's hand Explanation: To decrease ticklishness, have the child help by placing the hand under the nurse's hand, using age-appropriate distraction and conversation focused on something other than the exam.

The nurse should intervene when observing which parental action as a child is placed in a motor vehicle leaving the hospital? An infant is placed in a forward facing car seat. A 12 year old child is buckled into the front passenger seat. A 5 year old child is placed forward facing in a booster seat. A 2 year old child is placed in the back car seat.

An infant is placed in a forward facing car seat. Explanation: The infant seat should be in the back seat, facing backward, for at least the fi rst year of the child's life. Depending on the construction of the car seat, it may be in the back seat facing backward until the child weighs 30 to 35 lb. A child may face forward after 1 year of age in some types of car seats. At 4 years of age (or at 40 lb), the child may switch from a car seat to a booster seat. The child should be seated and restrained with the automobile's seat belt in such a booster seat, which is designed for use until he or she is at least 49-in. tall.Children who have outgrown the booster seat should ride in the back with a seat belt fastened securely. A child may move to the front seat after 12 years of age if he or she is of adult size. Front air bags have been known to hurt younger and smaller children because of the force with which they are deployed.v

A young child presents to the emergency department exhibiting intercostal retractions and abdominal breathing. What is the nurse's priority action? Apply oxygen via nasal cannula Transport the child for chest x-ray Encourage prolonged exhalation by having child blow up a balloon Provide reassurance to calm the child

Apply oxygen via nasal cannula Explanation: Children in physiological distress compensate with increased respiratory and heart rates. Physiological distress usually results from a respiratory disorder or significant blood loss. (Even children with a known congenital heart problem rarely present in acute distress from ischemic heart disease.) The additional work of breathing is evidenced in a distressed child by nasal flaring accompanied by supracostal, intercoastal, and subcostal chest retractions (Fig. 27.2) or abdominal breathing. <insert Fig. 27.2> Administration of oxygen and support of the child's ability to breathe are the first interventions. Physiological distress is priority to address, then reassurance and efforts to calm the child can be attempted. Oxygen should be applied before a chest x-ray is obtained. Oxygen can be worn during the x-ray. Prolonged expiration is not the priority treatment during acute distress until oxygen is applied and a complete assessment is performed.

A mother of a 4 year old child calls the clinic nurse because her child has swallowed some type of cleaning agent. What is the nurse's best response? Administer ipecac syrup per directions on bottle. Bring the child to the emergency department for administration of activated charcoal. Call the Poison Help Line #1-800-222-1222 for instructions on treatment. Monitor the child closely and bring to the clinic if symptoms appear.

Call the Poison Help Line #1-800-222-1222 for instructions on treatment. Explanation: The American Association of Poison Control Centers (AAPCC, n.d.) provides information needed for the home or hospital treatment of a child who has ingested a toxic substance. The Poison Help Line number is 1-800-222-1222. Recommendations might include use of ipecac syrup, activated charcoal, or both. Parents can buy these medications without a prescription; however, they should be used only when instructed to do so by the AAPCC. Currently, these medications are not recommended for home use because they have been used inappropriately in the past. The AAPCC provides telephone stickers or magnets with its emergency phone number to be posted on or near telephones. The nurse's best response is to instruct the mother to call the Poison Help line.

A nurse auscultates the heart rate in a young child and notes an irregular rhythm. No other abnormal vital signs are present and the child is not in any distress. What is an appropriate action by the nurse in regards to this finding? Turn the child to the left side and listen with the bell of the stethoscope Obtain an order to place the child on a heart monitor Ask the mother if the child has a history of cardiac problems Count the apical pulse for a full minute to obtain an accurate rate

Count the apical pulse for a full minute to obtain an accurate rate Explanation: An irregular heart rate in an otherwise stable child is most often a sinus arrhythmia and does not require intervention. The nurse should count the apical pulse for a full minute to obtain an accurate heart rate.

The nurse identifies the need to assess a child's motor, language and social development. What test would be most appropriate? Blackboard Screening Denver Developmental Screening Hirschberg Screening Apgar Scoring

Denver Developmental Screening Explanation: The Denver Developmental Screening Test is used for the developmental evaluation of children aged 1 month to 6 years. It evlauates personal/social, langueage, fine and gross motor skills. Blackboard and Hirschberg are vision screening exams. The apgar is calculated at 1 and 5 minutes after birth.

A nurse notes the respiratory rate of a 2-year-old to be 28 breaths per minute. What is an appropriate action by the nurse in regards to this finding? Percuss to assess for a consolidation Report the finding to the health care provider Document the finding in the child's chart Auscultate lungs for adventitious sounds

Document the finding in the child's chart Explanation: The normal respiratory rate for a child between the ages of 2 and 10 is 20 to 28 breaths per minute. The nurse should record this normal finding in the child's chart.

The nurse is collecting the history on a child and discovers that the child has missed a recommended vaccination. What is the nurse's best recommendation? Continue with next scheduled vaccination. Suggest receiving missed vaccination after age 18. Encourage a catch up dose as soon as possible. Avoid annual flu vaccine due to missed dose of scheduled vaccine.

Encourage a catch up dose as soon as possible. Explanation: For children who have not received that full roster of recommended vaccinations, the nurse should encourage catch up doses as soon as possible. The child should not wait until age 18 or for next scheduled vaccination. The flu vaccine is recommended annually regardless of missed vaccine.

Upon assessment of the child's eyes, they deviate inward. The nurse recognizes this as what? Farsightness Nearsightedness Exophoria Esophoria

Esophoria Explanation: Esophoria is eye deviation inward. Exphoria is eye deviation outward. Nearsightedness is the ability to see up close. Farsighted people are unable to see distances.

The nurse is doing an initial assessment on a school age client admitted to the pediatric unit in sickle cell crisis. When inspecting the eyes, the nurse finds that they are normal. How would the nurse chart these findings? Eyes are WNL Eyes are PERRLA. EOMs are at 180 degrees. Corneal light reflexes are equal Eyes are PERRLA with corneal light reflexes equal bilaterally Eyes are PERRLA with EOMs at 180 degrees bilaterally

Eyes are PERRLA. EOMs are at 180 degrees. Corneal light reflexes are equal Explanation: Normal findings would be documented as follows: eyes are PERRLA. EOMs are at 180 degrees. Corneal light reflexes are equal. There is no deviation during the cover and alternate cover tests. Fundoscopic examination reveals a distinct disc with no vessel nicking. This makes options A, C, and D incorrect.

The mother of an 8 year old girl expresses concern about feeling a lump at each of the child's areolas. What is the nurse's best response? Is there a history of breast cancer in your family? Pubertal changes at age 8 are abnormal and require further evaluation. It is likely a breast but which is a normal finding at this age. She will likely be prescribed hormonal replacement therapy.

It is likely a breast but which is a normal finding at this age. Explanation: Breast development begins with a "breast bud" or enlargement of the areola followed by enlargement of breast tissue .Onset of pubertal changes before 8 years in girls and 9 years in boys may be too early and needs further evaluation.

A nurse finds that a 14-year-old girl's breasts are red, edematous, and tender. Which of the following conditions should she suspect? Trauma Gynecomastia Precocious puberty Mastitis

Mastitis Explanation: Redness, edema, and tenderness in the breasts indicate mastitis. Enlargement of the breasts in adolescent boys suggests gynecomastia. Masses in the adolescent female breast usually indicate cysts or trauma. Breast development before age 8 may indicate precocious puberty or thelarche.

While performing an assessment on a 14 year old, the nurse notes the child has limited range of motion of the neck. The nurse recognizes this could be caused by what? Meningitis Esophoria Lymphanitis Exophoria

Meningitis Explanation: Limited neck ROM requires further evaluation for possible meningitis. Tender swollen lymph nodes of the neck and back of the head may indicate an infection or lymphanitis. Esophoria is inward deviation of the eye. Exophoria is outward deviation of the eye.

During a routine health supervision visit, the nurse is planning to focus teaching on behaviors and habits with an adolescent patient. What topics will the nurse discuss with the patient? (Select all that apply.) Puberty Nutrition Exercise Self-concept Computer screen time

Nutrition Exercise Computer screen time Explanation: The content that would be discussed with an adolescent regarding behaviors and habits during a health supervision visit includes nutrition, exercise, and computer screen time. Puberty and self-concept would be included in a discussion regarding social and emotional development.

The nurse is preparing to perform an assessment on a toddler. Where should the nurse position the child? Standing On the examination table On the parent's lap Stool

On the parent's lap Explanation: A toddler can remain in the parent's lap to decrease anxiety. An examination table may increase anxiety, a stool is not safe and a toddler will not remain inactive long enough to stand

What developmental area does the DDST-II evaluate? Cooperation Personal social Education Cognition

Personal social Explanation: The DDST-II is considered a gold standard for the developmental evaluation of children aged 1 month to 6 years. It evaluates four developmental areas of interest: personal social, language, fine motor/adaptive, and gross motor. The DDST-II does not evaluate education, cooperation, or cognition.

A pre-teen client has been admitted to the pediatric unit with bilateral lower lobe pneumonia. When writing a plan of care for this client, what would be the most appropriate intervention? Identify normal findings in the client Provide information for age-appropriate community activities Provide information that contributes to an improved state of health Assess parenting

Provide information that contributes to an improved state of health Explanation: The most pertinent intervention is to provide information that contributes to an improved state of health. Parenting would be assessed throughout childhood but is not the most appropriate intervention for a pre-teen client with pneumonia. Identifying normal findings is a simple distracter for this question. Age-appropriate community activities are not a concern for a client with a respiratory infection.

During the health assessment interview, a nurse should ask the parents of a 9-year-old male questions related to which activities to elicit age-related development of psychosexual stage? Pleasure centers on masturbation and genitalia Engages in masturbation and sexual activities Relative sexual indifference and interaction with same-sex peers Activity centers on expulsion and retention of body waste

Relative sexual indifference and interaction with same-sex peers Explanation: School-age children who are in the latency period of the psychosexual development stages have sexual indifference and tend to interact with same-sex peers. In a preschooler, pleasure is centered on masturbation and genitalia. Adolescents engage in masturbation and sexual activities with others. In toddlers, the erogenous zones are the anus and buttocks, and their activities are centered on expulsion and retention of body waste.

The nurse would suspect appendicitis as the cause of pain if the child pointed to what location? Right upper quadrant Right lower quadrant Left upper quadrant Left lower quadrant

Right lower quadrant Explanation: If a child points to pain in the right lower quadrant, appendicitis should be ruled out.

The nurse is conducting a health history with an adolescent patient. What should the nurse explain to the patient about confidentiality? The only thing that I can share with your parents is if you are sexually active. Since you are a minor, your health history is to be shared with your parents. The only thing that I must share is information that concerns your safety. Everything that is discussed will be kept confidential.

The only thing that I must share is information that concerns your safety. Explanation: The nurse should never make confidentiality unlimited and will need to act on information that threatens the patient's safety. The health history is not to be shared with the parents, including sexually activity.

The nurse is performing an assessment on a toddler and observes a protuberant abdomen. What is the significance of this finding? The toddler may have toxic megacolon. This is a normal finding for a toddler. The toddler may have an intestinal obstruction. The toddler may have worms.

This is a normal finding for a toddler. Explanation: A protuberant abdomen is a common finding for a toddler.

The nurse suspects that a school-age child would benefit from a referral to a health care provider who specializes in the neurologic system. What did the nurse assess to make this clinical determination? Bow-legged Knock-kneed Unstable gait Limps when walking

Unstable gait Explanation: An abnormal neurologic finding in a school-age child is an unstable gait. Bow-legs are common in toddlers. Knock-knees are common in children aged 2 to 7 years. Limping when walking could indicate congenital hip dysplasia in a toddler or ill-fitting shoes.

What is an appropriate action by a nurse when asking a child about the presence of pain? Use a pain scale appropriate for the child's developmental level Validate the child's verbal response with body language Palpate for pain because asking questions may lead to inaccurate data Ask the parent to validate the child's response

Use a pain scale appropriate for the child's developmental level Explanation: Pain is a subjective finding and both the parent and child should be asked about the presence of pain, especially in smaller children because they may have trouble verbalizing how they feel or where it hurts. The use of pain scale appropriate to the age of the child will help the nurse to obtain data about how severe the pain is. The FACES or the Oucher scales are appropriate to use with small children. The numeric scale may be used with older children and adolescents.

The nurse determines the heart rate of 100 beats per minute for a 5-year-old patient as being: Evidence of a valve disorder Sinus bradycardia Within normal limits Supraventricular tachycardia

Within normal limits Explanation: The average heart rate of a 5-year-old patient is 103 beats per minute, with the range being from 68 to 138 beats per minute. Sinus bradycardia is a heart rate less than 60 in a 5-year-old patient. A heart rate of 100 beats per minute in a 5-year-old patient is not evidence of a valve disorder. A heart rate of up to 240 beats per minute would be assessed in supraventricular tachycardia.

While assessing a 4-year-old child, the nurse observes that the child's nails are concave in shape. The nurse should assess the child for a deficiency of iron. vitamin C. magnesium. zinc.

iron. Explanation: Concave shape, "spoon nails" (koilonychia) indicate iron deficiency anemia.

It is often difficult to assess the location of pain in a child because generally children cannot acknowledge their pain feel their pain isolate their pain sense their pain

isolate their pain Explanation: Children usually cannot isolate pain to one specific area.

The nurse is going to examine a child with suspected sexual abuse. What piece of data would be a strong indicator of sexual abuse? perianal lacerations extending to external sphincter herpes in the anogenital area beyond the neonatal period condyloma acuminata in a child older than 3 years of age marked dilatation of the anus in knee-chest position

perianal lacerations extending to external sphincter

While communicating with an ill 5-year-old child, one of the most valuable communication techniques that the nurse can use is direct communication. indirect communication. closed-ended questions. play.

play. Explanation: Play is one of the most valuable communication techniques when working with children; it allows for the discovery of important clues to children's development and illness behaviors.

A young mother visits the clinic with her 18-month-old child. The mother asks the nurse when she should begin toilet training with the child. The nurse should explain to the mother that bowel training is usually started when the child is 3 years of age. she can begin bowel training as soon as the child appears ready. nighttime bladder control is usually achieved by 3 years of age. bladder training usually begins at 18 months of age.

she can begin bowel training as soon as the child appears ready. Explanation: Toilet training is a major task of toddlerhood. Readiness is not usual until 18 to 24 months of age. Bowel training occurs before bladder; night bladder training usually does not occur until 3 to 5 years of age.

After examining the breast development of a 13-year-old girl, the nurse records breast and nipples appear as small mounds with areolar development evident. The appropriate stage of maturity would be stage 1 stage 4 stage 3 stage 2

stage 2

A woman who speaks primarily Spanish at home brings her 3-year-old to the clinic for a yearly visit. The mother reports concern that her child's language skills are not progressing as expected. The health care provider may have a difficult time assessing this child's language capabilities if the mother does understand normal growth and development the family recently immigrated the provider is not bilingual the mother does bring a translator

the provider is not bilingual Explanation: Assessment of language development is difficult if the health care provider is not bilingual and the child speaks another language.