Prep-u: Chapter 10: Health Assessment of Children

The mother of a 2-month-old child reports her baby "breathes fast". When questioned further, the child's mother states she has counted the times using her watch and it was sometimes as high as 30 breaths in a minute. What is the best response by the nurse?

"Babies breathe rapidly and the amount you are reporting is within normal limits."

The nurse is assessing a newborn child. The mother asks why the newborns feet are blue. What is the best response by the nurse?

"Blueness of hands and feet is a common finding in newborns. It is a result of their circulatory system switching from being in the womb to life outside the mom's body." Blueness of the hands and feet, known as acrocyanosis, is normal in babies up to several days of age and results from an immature circulatory system completing the switch from fetal to extrauterine life. Although blueness in hands and feet may indicate a lack of oxygen and may be called peripheral cyanosis, acrocyanosis is a normal finding in a newborn.

The parents of an 8 year-old state, "I am happy that our child is healthy," when the nurse says that the child falls into the 95th percentile for BMI. How should the nurse respond?

"For a child a BMI between the 85th and 95th percentile alerts us to the risk for being overweight. Let's talk about your child's diet and activity level."

A nurse is caring for a very shy 4-year-old girl. During the course of a well child assessment, the nurse must take the girl's blood pressure. Which approach is best?

"Help me take your doll's blood pressure" It is best to approach a shy 4-year-old by introducing the equipment slowly and demonstrating the process on the girl's doll first.

The nurse is preparing to assess the internal ear structures of a 3-year-old. The child is resistant to the otoscope. How should the nurse respond?

"Let's see if I can find some puppies or kittens." The nurse should try to gain the youngster's cooperation by playing a funny pretend game using the "puppies or kittens" to engage the child.

A 14-year-old boy has come to his primary-care physician's office for a routine well-child visit. In reading the child's history, the nurse notes the child's father suffers from alcoholism. If the child's mother makes the following statements, which statement would be important for the nurse to gather further data regarding?

"Our next door neighbor is older than my son, and he drinks when they hang out together."

The nurse is discussing taking a temperature on a child with a group of nursing students in a post-conference setting. Which statement made by the nursing students is most accurate related to taking a temperature?

"Rectal temperatures should not be taken on a child with diarrhea."

The nurse is assessing a 6-month-old child. The mother asks when the soft area in her child's head will go away. What is the best response by the nurse?

"The area is called the anterior fontanel and typically closes anytime between 9 and 18 months of age." The anterior fontanel typically closes by the age of 9 to 18 months. Fontanels are soft areas on the skull that remain open in infancy to allow for rapid brain growth in the first months of life.

The mother of a 2-year-old asks the clinic nurse why her child's blood pressure is never measured. The mother states, "My blood pressure is measured during each visit to the doctor." What is the best response by the nurse?

"Typically, children younger than 3 don't need blood pressure measured unless they have a serious or chronic condition." Children younger than 3 years old should have blood pressure measured if they have certain risk factors such as prematurity, low birth weight, systemic illnesses, or congential heart disease

The nurse is gathering data from the caregiver of a 3-year-old boy. While in the waiting room, the nurse heard the caregiver say the boy feels nauseated. In interviewing the child's caregiver, what would be the most appropriate initial question for the nurse to ask?

"What caused you to decide to bring your son to the clinic today?"

A nurse realizes the importance of nutritional assessment during the health history. When doing so, the nurse must assess the quality as well as quantity of food eaten. The best way to assess food intake is to do:

24-hour recall. Food intake is best obtained by asking a parent to describe a typical day (24-hour recall), listing what the child ate for each meal and between meals as well.

The nurse is assessing deep tendon reflexes on a child admitted for severe dehydration. The assessment reveals hyperactive reflexes. How should the nurse document this finding?

4+

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.

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. Cultural and spiritual dynamics are important in taking a health history. This age of child likes choices and is concerned about modesty and privacy. For pre-adolescents, letting children choose whether or not a parent is with them in the exam room and during the history is appropriate. In either event, it is important to speak with the adolescent alone at some point.

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 write the answers down. The family caregiver provides most of the information needed in caring for the child, especially the infant or toddler. Rather than simply asking the caregiver to fill out a form, it may be helpful to ask the questions and write down the answers

A 14-year-old female has been brought to the pediatric ambulatory care clinic for a "sports physical" by her mother. The teen tells the nurse she does not want to have her mother present during the examination. What action by the nurse is most appropriate?

Ask the teen's mother to wait in a separate area nearby until the physical examination has been completed.

While interviewing a mother about her infant son's illness, the nurse asks, "Why did you bring your son to the clinic today?" Which part of the health interview is this nurse currently in?

Chief concern/complaint

Parents bring a toddler age 19 months to the clinic for a regular checkup. When palpating the toddler's fontanels, what should the nurse expect to find?

Closed anterior and posterior fontanels By age 18 months, the anterior and posterior fontanels should be closed. The diamond-shaped anterior fontanel normally closes between ages 9 and 18 months. The triangular posterior fontanel normally closes between ages 2 and 3 months

A 6-month-old is admitted to the hospital because of a fever. When you obtain a health history, what data would you obtain first?

Details about the fever Health interviews typically begin with a history of the chief complaint, because this is what people want to talk about first and represents a primary health problem

During a routine physical examination of a 13 year old female the nurse notes the presence of a tender nodule just below the nipple on her right breast. Which action by the nurse is indicated?

Document the finding as normal. Adolescent females may have a tender nodule beneath the nipple. This signals the onset of puberty.

The nurse is examining the back and spinal area of a 14-year-old female. A small dimple is noted. What action is most appropriate?

Document the finding as normal. A normal pilonidal dimple is sometimes seen at the base of the spine. This finding should be documented. There is no additional study or evaluation of this area indicated at this time

A 4-year-old girl reports having ear pain. To examine the child's ear, how should the nurse proceed?

Grasp the pinna and pull up and back. The ear is examined in a child younger than 3 years of age by pulling the pinna down and back. In a child over 3 years old, the ear is examined by pulling the pinna up and back. These maneuvers straighten the ear canal so that the tympanic membrane can be visualize

The nurse is reviewing vital signs taken by the unlicensed assistive personnel on a group of toddlers. Which warrants follow up by the nurse.

Heart rate 60, respiratory rate 31

The nurse is taking vital signs on a group of assigned preschool children. Which assessment finding would indicate the need for further action?

Heart rate of 120 beats per minute The normal range for heart rate for a preschooler is between 65 and 110 beats per minute. The normal range for respiratory rate for a preschooler is between 20 and 25 breaths per minute

The nurse is beginning the examination of a 4-month-old infant. She takes the infant from the mother's arms to do the exam. Where should the nurse place the infant for the exam?

In the crib facing the mom

The nurse is conducting a physical examination of a healthy 6-year-old. Which action should the nurse do first?

Observe the skin for its overall color and characteristics The physical examination of children, just as for adults always begins with a systematic inspection, followed by palpation or percussion, then by auscultation.

A nurse is assessing an infant's reflexes. The nurse places his or her thumb to the ball of the infant's foot to elicit which reflex?

Plantar grasp

The nurse is assessing the growth of a premature infant. What would be the appropriate action by the nurse to complete this assessment?

Plot the infant's weight, height, and length on a growth chart. The assessment for growth for a premature infant entails plotting his or her weight, length, and height on a growth chart, which is then analyzed. If the infant is below the growth curve, they are not growing appropriately and interventions may be needed

A nursing student asks the nursing instructor to explain pulse oximetry measurements in child. The nurse is accurate in telling the student:

Pulse oximetry measures the oxygen saturation of arterial hemoglobin.

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

Take the apical pulse. Taking the apical pulse with a pediatric stethoscope and counting the rate for a full minute is the most accurate way to obtain the heart rate on an infant. The radial pulse should only be used in older children over the age of 10 as it is difficult to palpate accurately in children younger than 2 years of age because the blood vessels lie close to the skin surface and are easily obliterated

When obtaining a child's health history the child's biological data is assessed. What is the next thing to assess in the child's history?

The chief complaint of the child The next step in the health assessment is the reason for seeking treatment. Remember to include the child's reason because it may be different from that of the parent or caretaker.

The nurse is conducting a physical examination of a 5-year-old girl. The nurse asks the girl to stand still with her eyes closed and arms down by her side. The girl immediately begins to lean. What does this tell the nurse?

The child warrants further testing for cerebellar dysfunction. This indicates a positive Romberg test which warrants further testing for possible cerebellar dysfunction

What is typical of a grade II heart murmur?

The murmur is soft but easily heard.

The nurse is obtaining a client history and asks the caregiver the reason for the child's visit to the health care setting. What answer best describes what the nurse is doing in this process?

The nurse is determining the chief complaint.

When testing the deep tendon reflexes of a child, a four-point grading scale is used. What would a 1+ result mean for a reflex tested?

The reflex is diminished. On the four-point grading scale used in assessing deep tendon reflexes, 1+ indicates a diminished response. With 2+ as average, a grade of 3+ is brisker than average and 4+ is hyperactive. The reflex is absent at a grade of 0.

The mother of 2-year-old triplets is anxious and worried because one of the children does not seem to be at the same developmental level as her siblings. Which finding might indicate a need for further diagnostic testing to rule out intellectual disability in this child?

The tops of her ears are below the corners of her eyes. The alignment of the ears is noted by drawing an imaginary line from the outside corner of the eye to the prominent part of the child's skull; the top of the ear, known as the pinna, should cross this line. Ears that are set low often indicate intellectual disability.

The nurse is taking the health history for a toddler in the emergency department. The child's mother 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 6 weeks ago. What would the nurse recognize as is the client's chief concern/complaint?

Vomiting

A nurse is packing a bag with all of the equipment she will need to perform a complete physical assessment at a client's home. What will the nurse need? Select all that apply.

• Tongue depressor • Stethoscope • Ophthalmoscope • Thermometer

The nurse is obtaining the health history for a 9-year-old child who has been brought to the ambulatory care clinic with complaints of a backache. Which initial action by the nurse is most appropriate?

Ask the child when the pain started.

The nurse is obtaining a health history on a 10-year-old child and asks the parents about their health history, the health history of their other children, and of their parents' health history. The parents ask the nurse why this information is necessary. What is the best response by the nurse?

"The information can alert us to any disease process that might run in families."

The student nurse is performing an assessment of an infant. Which action by the student nurse requires further instruction by the instructor?

The student nurse asks the parents to step out of the room while performing the assessment It is often helpful for the parents to hold the infant during the assessment. This provides the infant with a sense of security during the assessment; therefore, it is not necessary for the parents to be asked to step out of the room during the assessment.