Chapter 34: Child Health Assessment
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?"
A nursing instructor is teaching about taking a health history and how to elicit a chief concern. The instructor realizes a need for further education when a student makes with statement?
"Intensity refers to how often the concern occurs during the day."
Which physical assessment data would the nurse find concerning and would warrant reporting to the physician?
A blood pressure of 128/80 in a preschool-aged child
The nurse is visualizing the ear canal and tympanic membrane of a 14-month-old boy. Which finding would warrant further investigation?
A bubble behind the tympanic membrane
A 4-year-old is ordered to have a hearing test. How should the nurse best prepare the child for this exam?
Allow the child to play with the tuning fork.
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?
Assess the heart and lungs first.
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 her head-to-toe assessment on a 2-year-old child, when would she examine the child's ears?
At the end of the exam in case the child gets upset
The nurse is assigned as an admissison nurse completing various health histories. Which types of questions will the nurse utilize to complete the required documentation? Select all that apply.
Closed-ended questions Open-ended questions
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.
When percussing the chest of an infant the nurse hears hyperresonant sounds. What action should the nurse take?
Document the finding.
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
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.
The nurse should instruct the pregnant client not to receive which vaccine?
Oral polio
The nurse is performing an examination of the eyes of a 7-year-old girl. Which finding would indicate that the third cranial nerve is intact?
Pupil constriction in response to light
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
The nurse is working at a pediatric clinic and is preparing an infant for a well child check-up and immunizations. How should the nurse prepare the infant for the visit?
The infant should be totally unclothed during the physical examination.
A nurse is assessing the fontanelles of a crying newborn and notes that the posterior fontanelle pulsates and briefly bulges. What do these findings indicate?
These are normal findings.
An 18-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.