E2 Chapter 5 Review Q

The nurse is providing education on deciduous and permanent teeth to the parents of a 5-year-old child. Which statement would the nurse include? a. Your child will have all 32 deciduous teeth by age 6. b. Upper teeth usually fall out before the lower teeth. c. Your child will not have all his permanent teeth until late adolescence. d. There are 20 permanent teeth that will grow in between age 6 and 8.

ANS: c All 32 permanent teeth are usually erupted in late adolescence. Children get the first of 20 deciduous teeth between the ages of 6 months and 5 years. Permanent teeth begin to erupt about the age of 6 as deciduous teeth fall out.

The nurse is assessing the head of a 6-month-old infant. Which finding is expected? a. Closed anterior fontanel b. Open posterior fontanel c. No palpable fontanels d. Open anterior fontanel

ANS: d The nurse would expect the anterior fontanel to be open. The posterior fontanel closes by 3 months of age. The anterior fontanel closes by 18 months.

When observing an 18-month-old child, the nurse notes a rounded belly, sway back, bowlegs, and a head that is proportionally larger than the body. How would the nurse interpret these findings? a. The child appears to be a normal toddler. b. The child is likely developmentally delayed. c. The child may have hypocalcemia from malnutrition. d. The large head is concerning, and requires a thorough neurological exam.

ANS: a The typical toddler has lordosis and a protruding belly. The head still appears somewhat large in proportion to the rest of the body. Because these are normal findings, there is no need to be concerned about developmental delays, malnutrition, or neurological problems.

When using the otoscope to examine the ears of a 2-year-old child, which technique would the nurse use? a. Pull the pinna up and back. b. Pull the pinna down and back. c. Hold the pinna gently but firmly in its normal position. d. Position the child prone while stabilizing pinna.

ANS: b The ear canal in infants and young children is shorter, wider, and more horizontally positioned than in older children. To adequately examine the tympanic membrane in young children. the pinna must be pulled back and down. In older children and adults, the pinna is pulled up and back. The pinna is not held in its normal position, and the child is not positioned prone.

The nurse is assessing a full term newborn infant. When describing the autonomic infant reflexes to the infant's parents, which statement would the nurse include? a. Autonomic reflexes disappear by 1 year of age. b. Autonomic reflexes include palmar grasp, stepping, and rooting. c. Autonomic reflexes are apparent beginning about 6 months of age. d. Autonomic reflexes continue until the preschool years.

ANS: b The palmar grasp, stepping, and rooting reflexes are three of several autonomic reflexes. The autonomic infant reflexes are present at birth in full-term infants, and some, like the Babinski, may persist until 2 years of age. They should not be present in preschool age children.

The nurse is assessing extraocular muscles in a 1-year-old. The corneal light reflex is reflected unevenly in the child's eyes. Which would the nurse do next? a. Perform the cover-uncover test. b. Refer the child for additional testing for strabismus. c. Test the pupils for consensual pupil constriction. d. Inform the parent that this will be rechecked at age 2.

ANS: b An asymmetric corneal light reflex after 6 months of age indicates a muscle imbalance. This child would need referral for additional testing. Strabismus can be detected with the cover-uncover, but it is unreliable in children under age 5. This child is too young. Pupillary constriction and accommodation do not relate to eye muscles, it tests cranial nerve II and III. Waiting to recheck at age 2 is inappropriate.

The nurse is obtaining measurements on an apprehensive 18-month-old client at a well-child check. Which technique is best for obtaining the height? a. Measure arm span to estimate adult height. b. Use a tape measure. c. Use a horizontal measuring board. d. Have the child stand and use the measuring arm of an upright scale.

ANS: c Children younger than 2 years old should be measured lying down, preferably on a horizontal measuring board, to get an accurate assessment of height. A tape measure would be used to measure head circumference. An arm-span measure is not an appropriate estimation of adult height.

At what age is it appropriate to change the sequence of the examination to head-to-toe? a. Infant b. Toddler c. Preschool child d. School-age child

ANS: d The school-age years are the first time a child is able to reliably cooperate with the examiner and not squirm, talk, or otherwise interrupt the exam. In younger children, it is essential to begin with the chest and thorax because the child needs to be quiet and at rest.

Which technique would best help the nurse assess a child's gait? a. Perform the Ortelani and Barlow maneuver. b. Perform the heel-to-shin test. c. Ask the parent if the child has any problems ambulating. d. Observe the child moving about the examining room.

ANS: d The easiest way for a nurse to observe a child's gait is to unobtrusively observe the child moving about the examining room. If that is not possible, the nurse can ask the child to walk across the room at the conclusion of the physical assessment. The Ortelani and Barlow maneuvers assess for congenital hip dislocation in infants. The heel-to-shin test assesses coordination. Asking the parents about problems ambulating may be a helpful question, but is not definitive.