EXAM 5 prep u w&C chapter 28

The nurse is measuring the head circumference of a 1-year-old infant during a well-child visit. The parent asks the nurse why this assessment is being performed. Which response will the nurse provide to the parent?

"Head circumference is typically assessed until age 2 or 3 to help determine if growth is appropriate."

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."

The nurse is preparing to obtain anthropometric measurements on a child. The child's mother asks the nurse, "What are these measurements?" Which response by the nurse would be most appropriate?

"These are measurements that tell us how your child is growing."

The nurse is teaching parents of a 2-year-old toddler with cellulitis about temperature measurement. Which statement by the parents demonstrates the need for further teaching?

"We should verify any fever using a rectal thermometer for accuracy."

The nurse is teaching a group of novice nurses how to assess bowel sounds. Which statement will the nurse include in the education?

"You should auscultate all four quadrants for a full minute each."

The nurse is caring for an infant involved in a motor vehicle accident. The nurse uses the modified coma scale for infants and notes the following: spontaneous eye opening, moaning to pain, and withdraws to pain. Which score will the nurse record?

10

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

3 years

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

36 months

The nurse is interviewing an adolescent. What should the nurse recognize as an important aspect of interviewing the adolescent?

Adolescents will share more about themselves in a private conversation.

The nurse is assessing heart rate for children on the pediatric ward. What is a normal finding based on developmental age?

An infant's rate is 90 bpm.

The nurse obtains a rectal temperature for an 11-month-old infant. Which action will the nurse perform?

Apply water-soluble lubricant to the probe.

When 12-year-old Chelsie comes in for her annual check-up, the nurse must take a health history and do a physical exam. What is the most appropriate manner for the nurse to obtain a health history?

Ask Chelsie if she minds if her mother is in the room with her.

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 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 nurse enters a room to perform an assessment and finds the 9-month-old client asleep in the father's arms. Which action will the nurse take first?

Assess the infant's respiratory status.

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.

While performing an assessment on a child, the nurse notes the child's caregiver avoids eye contact with the nurse and is very soft-spoken. Which action by the nurse is best?

Continue with the assessment.

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.

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

The pediatric nurse is caring for an 8-month-old infant and notes that the infant sucks half-heartedly while drinking a bottle of formula. Which action by the nurse takes priority?

Determine if this is a change from previous behavior.

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

Document the finding.

When assessing heart sounds on a high school athlete, the nurse hears a "lub d-dub" sound which is associated with inspiration. What action will the nurse take?

Document the findings as normal.

The registered nurse (RN) observes the unlicensed assistive personnel (UAP) take a rectal temperature on a 6-month-old client diagnosed with diarrhea. Which action by the RN is appropriate?

Educate the UAP on when to avoid taking rectal temperatures.

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?

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.

A parent brings the child into the clinic and states that the child cannot hear well. Which characteristics in the child may indicate hearing difficulty? Select all that apply.

Responding inappropriately in conversation Speaking loudly Not speaking clearly Not responding when spoken to

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

Rhonci

To obtain an accurate heart rate in an infant, what would be most important for the nurse to do?

Take the apical pulse.

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.

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 nurse is conducting a health interview with the mother of a child coming to the clinic for an initial visit. Which question would be most appropriate for the nurse to ask the mother to elicit the chief complaint?

What is the reason for your visit today?"

On which client would it be appropriate for the nurse to perform a rectal temperature?

a child who has suffered a head injury and is comatose

A nurse is assessing a 3-year-old child in the local health clinic. The child has a persistent cough on examination. Based on the age of the child, which muscle would the nurse view to assess respiratory status?

abdominal muscle

The nurse is assessing the heart rate of a healthy 13-month-old child. The nurse knows to auscultate which site to obtain an accurate assessment?

apical pulse at the third or fourth intercostal space

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

When the nurse performs a head-to-toe assessment on a 2-year-old child, when would the examination of the child's ears occur?

at the end of the exam in case the child gets upset

A nurse is preparing to conduct a physical exam on a 7-month-old infant. Which area(s) will the nurse likely examine first? Select all that apply.

chest back

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 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 nurse is gathering data for a child's chart. What data needs to be collected as part of the child's health history? Select all that apply.

delivery information (type of delivery and complications) chronic diseases immunization status

While caring for a child recovering from viral pneumonia, the nurse examines the child's lungs for evidence of exudate and fluid. Which finding would suggest cause for concern?

dullness of his lower lobes heard on percussion

A pediatric nurse is gathering subjective data during the review of systems assessment for a child. Which method of organization will the nurse use to best perform this task?

head-to-toe exam

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

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

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

insepction

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 child and caregiver

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

The nurse assesses the heart of a 13-year-old and notes the presence of a fourth heart sound. What would the nurse do next?

notify the healthcare provider

The pediatric nurse is caring for a group of children of various ages. When assessing the children's blood pressures (BP), which child's reading should be reported to the health care provider? Select all that apply.

preschooler with BP 70/42 mmHg adolescent with BP 142/90 mmHg

The nurse is performing an examination of the eyes of a 7-year-old child. Which finding would indicate that the third cranial nerve is intact?

pupil constriction in response to light

The nurse is preparing to assess the pulse of an 18-month-old child. Which pulse would be most difficult for the nurse to palpate?

radial

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

The nurse begins the physical exam to obtain the child's vital signs. Which would the nurse assess first?

respirations

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

The nurse is taking vital signs on a 6-month-old infant. The caregiver reports that over the past 12 hours, the infant has had vomiting, diarrhea, and has been pulling on the ears. Which method(s) would be appropriate for taking this infant's temperature? Select all that apply.

temporal, axillary

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

The nurse is performing a physical examination on a sleeping newborn. Which body system should the nurse examine last?

throat

The nurse is assessing the abdomen of a 3-year-old. Which finding should be reported immediately?

visible peristaltic waves

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 nurse is assessing the head, eyes, ears and neck of an 8-year-old child. Which assessment finding(s) by the nurse would warrant further investigation? Select all that apply.

webbing of the neck inability to flex chin to chest

The clinic nurse is interviewing a parent about the infant's illness and is in the chief concern part of the health interview. Which question will the nurse ask during this part of the interview?

why did you bring your infant into the clinic today?