Ch 34 PrepU: Child Health Assessment

The nursing instructor is educating students on potential cardiac anomalies in newborns. The instructor knows additional information will be needed when a student makes which statement?

"I would assess the brachial pulse for coarctation of the aorta." When assessing the circulatory system of the newborn, assess the heart rate apically because the peripheral pulses may be too faint to be counted accurately. Always assess femoral pulses in newborns to rule out coarctation of the aorta. SPAO2 is important to assess in the infant with tetralogy of Fallot because it is a cyanotic heart defect. The lung sounds should be assessed regularly in babies with patent ductus arteriosus because of the increased fluid circulating to the lungs. Assessing the apical pulse is not specific to ventricular septal defect, but the pulse should be assessed in every child with congenital heart defects.

Where is the point of maximal impulse (PMI) found in a 5-year-old child?

4th intercostal space The area of most intense cardiac pulsation, or point of maximal impulse (PMI), varies with age. Up until the age 4 years it is located between the 3rd and 4th intercostal space (ICS). From ages 4 to 6 years it is found at the 4th ICS medial to the left midclavicular line. From age 7 upward it is located at the 5th ICS lateral to the left midclavicular line. Heart sounds radiate and can be heard either to the right or left of the sternum but never directly over the sternum. The clavicle is located too high to hear heart sounds.

The nurse is caring for a toddler who was just diagnosed with a hearing impairment. What would the nurse expect to assess in the child?

A delay or lack of clear, understandable speech pattern A hearing impairment will often cause a delay or absence of normal speech and language development in a child. Toddlers typically do not vocalize the sounds of the letter 'R" and "S" until older. Purulent drainage may represent an ear infection. Oxygen at birth may be problematic for vision, but not hearing.

As part of a class assignment a nursing student will teach fellow classmates how to conduct a physical assessment on an infant. What priority information should the student teach?

As a rule, assess the heart and lung function first. Conduct the intrusive procedures such as ear and throat assessment last so an infant does not cry and complicate the remainder of the examination. Proper restraint enables an examiner to see well and also to ensure the instrument such as an otoscope will not accidentally cause injury. As a rule, do not ask parents to restrain during any procedures in which the child will feel threatened or feel pain. Parents are best used as protectors and comforters after the exam. Temperatures should be taken temporally.

The nurse is assessing the cardiac sounds of a child. Which action would the nurse incorporate into the assessment?

Auscultate the heart rate at the point of maximal impulse (PMI) to best interpret the cardiac sounds. The nurse would auscultate the child's heart sounds in the area of the PMI. The nurse would listen for a full minute, not 30 seconds x 2, which is not as accurate. The nurse would assess the child's heart sounds in the upright position and in the reclined position. The nurse would assess over four valvular areas of the heart, not three.

A 2-year-old child with a 3-day history of diarrhea is brought to the urgent care clinic by the caregiver. The nurse determines the child's axillary temperature is within the normal range based on which finding?

Axillary temperatures are taken on newborns, on infants and children with diarrhea, and in other cases when a rectal temperature is contraindicated. An axillary temperature usually measures 0.5 to 1.0 degrees lower than the oral measurement. A normal oral temperature range is 97.6°F to 99.3°F (36.4°C to 37.4°C). A rectal temperature is usually 0.5° to 1° higher than the oral measurement.

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

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

The charge nurse observes a new graduate nurse assess the cremasteric reflex in an 8-month-old boy. The new graduate nurse strokes the lateral aspect of the thigh. Which action should the charge nurse take?

Demonstrate the appropriate technique. A cremasteric reflex is elicited by stroking the medial aspect of the thigh in boys. With this, the testes move perceptibly upward. The presence of this reflex indicates integrity of the first and second lumbar nerves. Abdominal reflexes should be assessed in both sexes. An abdominal reflex is elicited by lightly stroking each quadrant of the abdomen. Normally, the umbilicus moves perceptibly toward the stroke. Presence of this reflex indicates integrity of the 10th thoracic nerve and the first lumbar nerve of the spinal cord. The new graduate nurse needs to be shown the correct aspect of the thigh to stroke so that she/he can perform the technique correctly in the future. Explaining why the technique is incorrect does not show the nurse how to perform the procedure correctly. The charge nurse would not want to applaud an incorrect procedure, nor is this reason to counsel the nurse.

An 18-month-old infant is brought to the emergency room and the nurse notes a strong camphor-like smell. What should the nurse do first?

Determine the type of ingestion. Utilizing the sense of smell during a health assessment helps the nurse to focus on finding a source for the odor and the potential cause of the odor. When the smell of camphor is present the nurse should evaluate for the ingestion of mothballs. Urine that smells like maple syrup is a symptom of a protein metabolic condition. A sweet smell is associated with a pseudomonas infection. A putrid smell can be associated with fat in the stool from inadequate absorption. Prior to initiating any treatment it is important to find what the child has ingested if at all possible. The poison control center can provide antidotes and treatment protocols for all types of ingestion. The nasogastric tube and/or activated charcoal may or not be needed depending on the type of ingestion that has occurred.+

The nurse is performing a physical exam on a 3-year-old boy. What method would the nurse use to perform the exam?

Examine the child's head and work down to the child's toes. A preschool or toddler child should be examined starting from their head and working down all the way to their toes for a thorough exam. In infants, the examination starts with the chest, and then proceeds from head to toes.

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 a:

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.

A nurse is assessing a 14-year-old client who has just been admitted to an acute care facility and notices that the patient has halitosis. Which are the usual causes of this problem for this age group? Select all that apply.

Halitosis (bad breath) is usually caused by poor dental hygiene, lung infection, or foreign body in the respiratory tract.

The nurse asks the parents of a child about the family health history. The father asks the nurse why she needs his information. The nurse would explain that the family health history is gathered for what reason?

Identifying risk factors in families decreases the child's risk of developing the same conditions or health problems. Collecting a complete family health history helps the nurse learn if there are certain behaviors or risk factors for the family; this will hopefully educate the family in how to improve both their health and the child's health, as well as reduce the incidence of diseases and chronic conditions.

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?

The nurse should do any type of intrusive examination, such as of the mouth or ears, at the end of the physical exam so as not to distress the child. The other choices all could cause distress to the child before or during the exam.

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 records are important to know in a health history of any child. If the child is missing any immunizations, the nurse can then educate the parents about vaccines and assist in scheduling immunizations. The other choices are important to know when gathering a history, but the immunization history is the priority in this list.

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. For a school-age child, the nurse should include the child in all parts of the examination, and speak to the caregiver before and after the examination. For a newborn, the nurse should keep up a running dialogue with the caregiver, explaining each step as it is done. The nurse should speak to the early teen using mature language and appeal to his or her desire for self-care. For an infant, the nurse should address the child by name, and speak to the caregiver and do the most invasive parts last.

The nurse is assessing a 4-year-old child brought to the emergency department due to abdominal pain. Which method(s) will the nurse use to complete a focused symptom assessment? Select all that apply.

Providing symptom assessment on a child requires skill. Although data from the child is the best, the parents also have important data to contribute to the assessment due to the child's age. Having the child point to the area that hurts is an age-appropriate way to assess pain location. Parents can provide data on the symptoms that they see in their child, which actions cause pain, and which actions the child performs to try to alleviate pain. The nurse should ask the parents and child if there is anything else that hurts or is related to the pain (e.g., nausea, headache) and if this occurs in a specific setting like day care. The nurse would not try to trick the child to see if they are lying about the symptoms. This may frustrate the child.

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?

Screening for curvatures of the spine begin at school age when the child is most likely to develop this kind of deformity.

The nurse is working at a pediatric clinic and is preparing an infant for a well-child check-up and immunizations. How will the nurse prepare the infant once the client is escorted to the examination room?

The infant should be totally unclothed for the physical examination. The American Academy of Pediatrics states that infants should be fully unclothed when having an age-appropriate physical examination. This allows the infant's skin to be examined and areas exposed for auscultation. Weight is also obtained with the infant being naked. Diapering is acceptable after the examination and before the immunizations. There is no need to drape an infant or place the infant in a hospital gown with ties.

What is typical of a grade II heart murmur?

The murmur is soft but easily heard. When assessing heart murmurs, a grading scale is used to describe the sound of the murmur. A grade I murmur can barely be heard. A grade II heart murmur is usually soft and it is easily auscultated. A grade III murmur is audible. A grade IV murmur can be heard and has an associated thrill. The grade V murmur is loud and can be heard with the edge of the stethoscope lifted off the chest. The grade VI murmur is very loud and can be heard with the stethoscope near but not touching the chest.

The nurse is caring for a child who has just arrived to the emergency department. The child is pale and has labored breathing. The nurse is inspecting the child while placing the child on oxygen, obtaining a pulse oximeter reading, and raising the head of the bed. Which assessment finding best reflects that the child's respiratory status is due to a chronic condition?

The nurse begins the assessment by inspection as soon as the nurse enters the room. Clubbing of the fingers, which is a change in the angle between the nail bed and fingernail, identifies that the child has a chronic respiratory condition. The clubbing occurs from increased capillary growth as the body attempts to supply more oxygen routes (more capillaries) to distal body cells. A low oxygen saturation, retractions, and cyanosis can be reflective of an acute, not chronic, condition.

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?

The review of systems should be performed using a head-to-toe organization. Even though the pediatric exam may not always follow the head-to-toe organization, it is best to attempt this method in order to ensure that all systems are assessed. The other methods that may be used during the pediatric assessment; however, are not the best organizational methods to perform the review of systems assessment.

The nurse is caring for a child with diarrhea who has a rapidly fluctuating temperature. The nurse obtains an oral temperature and notes the child is febrile, where the child's temperature was within normal limits two hours prior. Which action will the nurse take?

Use a temporal thermometer to verify the reading. The temporal thermometer is gaining popularity because it can detect rapid temperature changes. Obtaining a rectal temperature should be avoided if other methods are available, as this may be very distressing to the child and should not be performed if the child has diarrhea. Retaking the oral temperature or comparing the reading with an axillary reading are not the best choices because these do not best detect rapid temperature changes.

The nursing student is preparing to explain the appropriate steps for assessing an infant. The instructor determines the student's presentation is successful after illustrating which location as appropriate for obtaining an apical pulse?

When taking an infant's apical pulse, the stethoscope is placed between the child's left nipple and sternum. The other locations will not assist with localizing over the apex of the heart.

A nurse is performing a physical examination on a newborn. Which assessment should the nurse include?

axillary temp, femoral pulse, and head circumference When examining newborns, take axillary or temporal temperatures to prevent rupture of rectal mucosa. Be certain to take femoral pulses in newborns to rule out coarctation of the aorta. Include newborn reflexes, head circumference, and an assessment of gestational age as routine parts of the examination. Taking blood pressure is not necessary because this value is unreliable in newborns.

A 6-month-old has fanning of the toes and dorsiflexion of the big toe seen on physical exam. Based on this finding the nurse should:

document as a normal finding. The infant should be assessed for a Babinski reflex. To achieve this stroke the sole of the foot. Fanning of the toes will occur in infants younger than 3 months of age. A downward reflex of the toes will occur beyond 3 months of age. Some infants will demonstrate a flaring Babinski sign until 2 years of age. In the absence of other neurologic findings this is a normal response. The nurse would document this normal finding. The child would not need to be referred for further evaluation. The finding does not indicate any particular type shoe the child would require.

The nurse has determined that it is important to complete a 24-hour nutritional recall for a school-aged child. Which instruction will ensure the most accurate results?

begin the food recall on a weekend day Nutritional intake is an important part of a child's growth and development. When concerns of adequate nutrition arise, it is important to obtain a recall of what has been ingested (foods and liquids) by the child on a typical day. To get a complete picture and promote child understanding, it is most important to ask for a weekend history, when the parent can assist in documentation and can supervise food offerings to the child. A child may have foods at school or after-school activities that the parent is unaware of. With understanding the goals of documenting nutritional intake learned on the weekend, the child may be more aware of accuracy. For accuracy, waiting to document until the end of the day is discouraged. It is best to document throughout the day as the intake occurs. There are many smartphone apps that provide documentation as soon as the child has eaten. Note cards can be misplaced if carried with the child throughout a busy day.

The nurse is measuring an infant's head circumference and charts it to be at the 40th percentile. When documenting the following physical measurements, which correlation to the head circumference is anticipated?

child's length will be at the 40th percentile Head circumference should correlate with the child's length; that is, if the child's length is in the 40th percentile, head circumference also should be. If the measurement of head circumference plots at different percentiles over time, this should be reported, as it is abnormal. The child's weight will not be double the head circumference. The chest circumference is not half of the head circumference. The abdominal circumference has no correlation to the head circumference.

The nurse is conducting the Denver Articulation Screening with a 5-year-old girl to assess her speech. Which of the following should the nurse do while conducting this exam?

convey impression that there are no right or wrong answers The Denver Articulation Screening is designed to detect significant developmental delays as well as normal variations in the acquisition of speech sounds. Because it is a standardized test, its directions must be followed precisely, not modified according to the nurse's own discretion. Before the test, explain the child will need to repeat the words she hears you speak. Give enough examples so you are certain she understands what she is to do: "When I say 'boat,' then you say 'boat.'" When you are certain the child understands the directions, say each of the 22 words shown on the Denver Articulation Screening form; do not have the child read the words from a sheet of paper. Convey the impression that there are no right or wrong answers. Give the child approval for responding and following directions correctly, no matter how inaccurately the child repeats the word; the nurse should not explain which words the child missed and why.

A toddler is brought to the pediatric clinic by the caregiver because the child "doesn't feel well." As the nurse interviews the caregiver about why the client is there, which goal is the nurse prioritizing at this point?

determining chief complaint The reason for a visit to a health care setting is called the chief complaint. In a well-child setting, this reason might be a routine check or immunizations, or an illness or other condition. The nurse will obtain this information by interviewing the caregiver. Obtaining the health history and biographical data will also be completed during the assessment process.

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 findings as normal With inspiration and the resulting increase or pressure in the lungs, the pulmonary valves close slightly later than the aortic valve. This causes a variation in heart sounds. This is termed physiologic splitting and is heard as a "lub d-dub" sound. As long as this sound is associated with inspiration, it is a normal finding. If splitting were to be consistently heard, it would indicate difficulty with the pulmonary valve closing and suggest pathology. Because this is a normal finding no referrals need to be made.

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 A Babinski reflex is part of the neurologic assessment of a newborn. When the newborn is touched or stimulated along the lateral side and ball of the foot, the toes fan.

When performing a lower extremity assessment which manifestation would be most important for the nurse to evaluate further?

limping The child should be assessed for range of motion in all the lower extremity joints, gait, and limping. Children who limp need further evaluation. A limp can be due to something simple (such as a blister on the foot from wearing new shoes) or it can also be a sign of a serious hip or bone condition. The joints should have full range of motion. This is important to check for developmental dysplasia of the hip in the infant. When assessing for gait, the nurse would see a wide-based gait in the toddler and may not get an accurate gait in the adolescent if he or she slouches while walking.

A nurse is testing a client for strabismus and amblyopia using the cover-uncover test. Which is the likely developmental age of the client?

preschool age child The cover-uncover test is reliable for assessing strabismus in children older than 2 years. One can test the corneal light reflex in children older from age 6 months to 24 months, but it is not reliable. If testing is not done until school age, a vision loss may have occurred.