Pediatrics Ch. 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."

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 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 prepares to complete a health history. Which question(s) will the nurse use to best assess the child's lifestyle? Select all that apply.

"What grade are you in?" "How many brothers and sisters do you have?" "What kind of foods do you eat?" "What do you like to do for fun?"

The nurse is collecting data on a 12-year-old client being seen for an annual examination. The client reports mild nasal drainage believed to be related to seasonal allergies. Which question(s) will the nurse include in the data collection process? Select all that apply.

"What time do you go to sleep and wake up each day?" "Do you have any pets that live in your home?" "Do you believe you have good relationships with friends?" "Are you taking any medication at home currently?" "Can you describe what you typically eat in a day?"

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?"

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."

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 obtains vital signs on four pediatric clients. Which finding will the nurse report to the primary health care provider?

4-year-old client with a heart rate of 130 beats/minute and blood pressure 115/80 mm Hg

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 caring for a 9-year-old client admitted for a fractured tibia. The client expresses fear over being in the hospital. Which intervention will the nurse include when caring for this client to build a trusting relationship?

Answer questions about pain honestly.

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.

A nurse is assessing a 3-year-old child. Which would be appropriate ways to approach the child during the exam? Select all that apply.

Ask the child if he/she would prefer to sit on the parent's lap for the exam. Give reassurance to the child during the exam.

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 is preparing to conduct a physical examination of a 3-year-old child. Which assessment will the nurse introduce for the first time to this client?

Blood pressure recording

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 licensed practical nurse (LPN) and registered nurse (RN) are caring for a 4-year-old client diagnosed with gastroenteritis with vomiting and diarrhea. On admission, the client's vital signs were: pulse, 70 beats/minute respiratory rate, 26 breaths/minute blood pressure, 76/38 mm Hg axillary temperature, 101.4°F (38.5°C) The RN tells the LPN to obtain a rectal temperature on the client. Which action by the LPN is appropriate?

Clarify with the RN the appropriate location to obtain the client's temperature.

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.

Place in order the steps the nurse would implement when gathering the following physical data for an infant?

Count respirations Count the apical pulse Examine the infant's genitalia Measure the infant's chest and head circumferences. Obtain the infant's axillary temperature Look into the ears and mouth

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 nurse is preparing to obtain the head circumference of a 2-year-old client. Place the steps in the order the nurse will complete them to obtain an accurate head measurement. Use each step once.

Explain the procedure to the client and caregiver. Position the client on an exam table or caregiver's lap. Place a tape measure around the client's head. Ensure the tape measure is just above the eyebrows and around the most prominent part of the back of the head. Record and plot the measurement on a growth chart.

The nurse is attempting to obtain the blood pressure of a 5-year-old client. The client begins to cry and move about when the nurse nears the bed and screams when the blood pressure cuff is seen. The caregiver is present in the room with the client but is not sure what to do. What action is appropriate for the nurse to take?

Give the client a stethoscope, cuff, and doll to perform the procedure on.

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

Inspection

The licensed practical nurse is assisting to admit a pediatric client. Which action(s) by the nurse will help to build a trusting relationship with the client and family? Select all that apply.

Knock before entering the client's room. Face the child and family during the interview. Allow the child to play with toys during the interview.

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

Limping

The nurse is observing a novice nurse measure the head circumference of a 9-month-old infant. The nurse determines that the novice nurse is performing the skill correctly based on which action?

Measuring from above the eyebrows through the prominent part of the occiput.

The nurse obtains vital signs on a 7-year-old client diagnosed with a urinary tract infection (UTI). The client's heart rate is 126 beats/minute, tympanic temperature 102°F (38.8°C), and blood pressure 90/50 mm Hg. Which action will the nurse take next?

Notify the primary health care provider.

The nurse is obtaining respirations from an 8-month-old client. The client has an apnea monitor attached. Which action(s) is appropriate for the nurse to take when obtaining the client's respiratory rate? Select all that apply.

Observe the client when they are quiet and still. Allow the caregiver to hold the client while observing the client.

The nurse is caring for a 6-month-old client admitted with croup 2 days ago. The client has continuous pulse oximetry ordered and the device is in place. Which action is appropriate for the nurse to take while caring for this client's pulse oximeter?

Observe the site every 2 hours.

The licensed practical nurse (LPN) is assisting in the care of an infant. When observing the infant, the LPN notes the infant is not as active as usual, has no interest in surroundings or feeding, and turns the head fretfully from side to side. Which action will the LPN complete next?

Obtain the infant's vital signs.

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 assisting with the interview of a 16-year-old client. The client only speaks Spanish and the nurse only speaks English. The client's parent is present and is bilingual. Which action by the nurse is appropriate?

Stop the interview and obtain a facility-approved translator.

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 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

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 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

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

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

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 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 obtains vital signs on four infants. Which finding will the nurse highlight for the primary health care provider to review?

infant crying with a heart rate of 100 beats/minute and blood pressure 52/36 mm Hg

The licensed practical nurse (LPN) is assisting in the care of infant clients. Which client finding will the LPN report to the registered nurse (RN) for further assessment?

infant who lies quietly unless handled, then cries and makes no effort to lift head

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

respirations

The nurse is listening to the breath sounds of a 4-year-old child. Which sound should the nurse determine as being normal for this client?

rhonchi

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