Peds Chapter 28: PrepU

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

"Auscultated all four quadrants for a full minute each."

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."

A nurse is wrapping up a health interview with the parent of a toddler. Which would be the best question or statement to end the interview?

"Is there anything more about your child that we should know?"

The pediatric nurse is performing a health assessment on a child. Which question(s) will the nurse ask when determining the social history portion of the assessment? Select all that apply.

"What jobs do your mommy and daddy have?" "What church do you go to?"

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 to the clinic today?"

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

3 years

The nurse is conducting a health history for a 9-year-old child with stomach pains. What is a recommended guideline when approaching the child for information?

Allow the child to control the pace and order of the health history.

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 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.

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

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 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 assessing a Babinski reflex in a 2-day-old newborn. Which finding by the nurse would indicate a positive finding?

Fanning of the infant's toes

When auscultating bowel sounds, which of the following frequencies would the nurse identify as normal?

Five to 10 per minute

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

Which technique would you begin with to assess a child's abdomen?

Inspection

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

A 10-year-old has braces on her teeth. What is most important for the nurse to assess when inspecting the mouth?

Pinpoint ulcers on the gums

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

The nurse is measuring the blood pressure of a 12-year-old boy with an oscillometric device. The boy's reading is greater than the 90th percentile for gender and height. What is the appropriate nursing action?

Repeat the blood pressure reading using auscultation.

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

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 planning an education session for adolescent males on health promotion activities. Which topic should the nurse include as being the most applicable for this population?

Testicular self-examination

The nurse is gathering data on a child being admitted. Which would be considered collecting subjective data? Select all that apply.

The nurse finds out the reason for the child's visit to the health care setting. The nurse asks questions about the child's history. The nurse interviews the child's caregiver.

The nurse is performing a physical examination on a sleeping newborn. Which body system should the nurse examine last? Heart, lungs, abdomen or throat?

Throat

The nurse is preparing to perform a neurological assessment on a child involved in a trauma. Which action(s) will the nurse take when assessing the child's pupils? Select all that apply.

Use a bright flashlight Turn the flashlight on and bring it over the pupil Dim the lights

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