Chapter 29 EAQ

Which examination would the nurse perform after the abdominal assessment on a young child?

Genitalia

Which examinations would the nurse perform with the child lying on the table in the supine position? Select all that apply.

Genitalia Abdominal Lower extremity

Which intervention helps the nurse listen to the lung sounds in a young child?

Giving the child a pinwheel and asking the child to blow

Which reflex would be assessed when the nurse places a thumb in the infant's palm?

Grasp

Which assessment would the nurse evaluate as a young child plays with toys in the examination room?

Gross and fine motor skills

Which medical history findings of a 3-year-old child indicate normal growth and development? Select all that apply.

Has a positive red reflex Passed meconium 24 hours after birth Had a Babinski reflex until 2 years of age

Which action would the nurse take to examine the adolescent's inguinal area?

Have the adolescent lower pants under the drape.

Which action would the nurse take when examining the genitals of a male neonate?

Identify urethra position.

Which actions would the nurse take to assess a child's thorax and breath sounds? Select all that apply.

Inspect shoulder symmetry. Percuss over lung fields. Note any adventitious sounds.

Which actions would the nurse take to assess a child's head, face, and neck? Select all that apply.

Inspect symmetry of facies. Palpate trachea. Palpate thyroid gland.

Which action would the nurse take when performing a physical assessment on a young child?

Inspect the chest for pulsations on the precordium.

Which action would the nurse take after examining a child's ears?

Inspect the posterior chest.

Which assessments would the nurse include while examining the genitalia of a female neonate? Select all that apply.

Inspecting the labia and clitoris Assessing the presence of vernix caseosa Inspecting the presence of a patent vagina

Which assessment would the nurse include during the examination of a child's head and face?

Inspecting the size of the head

Which assessment would the nurse perform last during an infant examination?

Inspecting the tympanic membranes

Which assessments would the nurse include during an abdominal examination in a newborn? Select all that apply.

Inspecting the umbilical area Assessing the umbilical stump Counting the vessels in the cord Auscultating for bowel sounds

Which developmental characteristic would the nurse consider while performing a physical examination on an adolescent?

Is self-conscious

Which methods would trigger the Moro reflex in an infant? Select all that apply.

Jarring the sides of the infant's crib Startling the infant by making a loud noise Dropping the infant's head suddenly for a short distance

Which organ would the nurse be able to feel when performing deep palpation of the infant's abdomen?

Kidney

Which parameter would the nurse be assessing for when using the Denver II test?

Motor skills

Which technique would the nurse use to assess syndactyly in an infant?

Observe the toes.

Which assessments would the nurse include while examining the chest of an infant? Select all that apply.

Observing the chest for signs of retraction Auscultating for bowel sounds in the abdomen Palpating for the apical impulse and noting its location

Which assessments would the nurse perform in the child to determine heart function? Select all that apply.

Palpation of chest wall for thrills Auscultation of the S 1 and S 2 across the precordium Palpation of the apical impulse with notation of the location

Which parameters would the nurse assess while examining a child's abdomen? Select all that apply.

Periumbilical area Bowel sounds Femoral pulse

Which technique would the nurse use to perform a head-to-toe assessment on an infant?

Place infant under an overhead heating element.

Which action would the nurse take to elicit the tonic neck reflex in an infant?

Place the infant in a supine position on an examination table during the test.

Which action would the nurse take to elicit the placing reflex in an infant?

Position the infant against the edge of the examination table.

After assessing a 15-month-old infant, which finding would alert the nurse to impaired neuromuscular development?

Presence of the plantar grasp reflex

Which vital signs would the nurse generally take while assessing a healthy neonate? Select all that apply.

Pulse Respiration Temperature

Which parameters would the nurse assess while examining a child's upper extremities? Select all that apply.

Radial pulse Palmar creases

Which parameter would the nurse be assessing in a newborn by using the Apgar scoring system 5 minutes after birth?

Response of the newborn to extrauterine life

Which body part would the nurse assess to examine the trunk incurvation reflex in an infant?

Spinal column

Which parameters would the nurse assess for when lightly palpating an infant's abdomen? Select all that apply.

Spleen tip Muscle tone Urinary bladder

Which reflex would the nurse observe when a newborn starts to cry and extends the legs, arms, and fingers when there is a loud noise?

Startle

Which reflex would be assessed when the nurse inserts a gloved little finger into the newborn's mouth?

Sucking

Which intervention would the nurse incorporate to open the eyes of a neonate for an examination?

Support the head and shoulders and gently lower the neonate backward.

At which age in years would a positive Babinski reflex in a child be a normal finding?

1

At which time would the nurse perform the initial Apgar test in a newborn?

1 minute after birth

Which actions would the nurse perform to detect ear disorders in a newborn? Select all that apply.

Complete an otoscopic examination. Note the presence of the startle reflex caused by a loud noise.

Which parameters would the nurse assess in a child by using an otoscope? Select all that apply.

Condition of the auditory canal Intactness of the tympanic membrane

The nurse pulls the infant's arm across its chest and finds that the infant's elbow does not cross the midline. How would the nurse report this finding?

Absence of the scarf sign

Which reflexes in a child would the nurse test by using a reflex hammer? Select all that apply.

Achilles Patellar Plantar

Which reflexes would the nurse test in a newborn by using the reflex hammer? Select all that apply.

Biceps Triceps

Which infant reflexes would the nurse test by using the penlight? Select all that apply.

Blink Pupillary Corneal light

Which areas would the nurse assess by using a penlight during a young child's physical examination? Select all that apply.

Buccal mucosa Nares and septum Corneal light reflex

Which technique would the nurse use to assess patency of the anus in a 1-day-old neonate?

Check for the passage of meconium.

Which area would the nurse assess to determine tactile fremitus in a child?

Chest

Which intervention would the nurse incorporate to assess a child's cardinal positions of gaze?

Direct a moving penlight in front of the eye.

Which reflex would the nurse be testing by slowly rotating the newborn from side to side?

Doll's eye

Which pulse would the nurse palpate to determine the blood supply to the child's lower extremities?

Dorsalis pedis

Which assessment would the nurse perform after the mouth and throat examination on a child?

Ears

Which intervention would the nurse use to gain a preschooler's cooperation during an otoscopic examination?

Encourage the preschooler to handle the otoscope.

Which assessment would help the nurse evaluate an infant's upper extremities?

Evaluating for the scarf sign

Which actions would the nurse take while performing a well-child examination in a preschooler? Select all that apply.

Explain the steps of the examination to the child. Ask the child to blow on a pinwheel to listen to the lung sounds. Ask the child to build a tower with blocks.

Which developmental considerations would the nurse remember when performing health screenings for a group of preschoolers? Select all that apply.

They prefer to be independent in doing tasks. They may withdraw from invasive procedures. They want to be helpful during the examination.

Which area would the nurse assess while an adolescent is sitting up at the edge of the examination table?

Thorax

Which activities would the nurse ask the preschooler to do during the Denver II test? Select all that apply.

Throw a ball. Build a tower. Stand on one foot.

For which reason would the nurse assess a young child's ear?

To check for a foreign body

For which reason would the nurse place an index card over a child's left eye during an eye examination?

To conduct the cover test

The nurse lifts the infant by supporting the shoulders and lets the infant's head drop back for which purpose?

To examine the neck

Which parameters would the nurse measure to plot on infant growth charts? Select all that apply.

Weight Length Head circumference

At which times would the nurse assess the symmetry of the facial features and positioning of the face in a newborn? Select all that apply.

When crying When sleeping