CH. 32 Prep U - Health Assessment of Children

The student nurse is caring for a child who weighs 48 pounds and is 38 inches tall. Which is the child's body mass index (BMI)? A. 23 B. 33 C. 32 D. 28

A. 23

A nurse is performing a physical examination on a newborn. Which assessment should the nurse include? A. Axillary temperature, femoral pulse, head circumference B. Rectal temperature, femoral pulse, head circumference C. Oral temperature, blood pressure, head circumference D. Temporal temperature, blood pressure, reflexes

A. Axillary temperature, femoral pulse, head circumference

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? A. Details about the fever B. History of past illnesses C. Family profile D. Review of systems

A. Details about the fever

When auscultating bowel sounds, which of the following frequencies would the nurse identify as normal? A. Five to 10 per minute B. One to two per minute C. Sixty per minute D. Thirty to 40 per minute

A. Five to 10 per minute

The nursing instructor is conducting a clinical session on the proper techniques for assessing a child's head circumference. The instructor should point out which factor concerning this assessment? A. Place the tape measure around the head just above the eyebrows. B. Measure the head circumference routinely on children up to the age of 6 years. C. Expect the head circumference and the chest circumference measurements to be equal up to the age of 6 years. D. Place the tape measure around the head with the tape touching just below the eyes.

A. Place the tape measure around the head just above the eyebrows.

The mother of a 9-month-old child reports her child's eyes are often crossed. The nurse confirms this during the examination. What action is indicated? A. Report the findings to the physician. B. Explain to the child's mother that this is normal until about one year of age. C. Document the finding as normal. D. Ask the mother if this was a problem in her other children.

A. Report the findings to the physician.

The nurse is gathering data on a child being admitted. Which would be considered collecting subjective data? Select all that apply. A. The nurse finds out the reason for the child's visit to the health care setting. B. The nurse interviews the child's caregiver. C. The nurse takes the child's vital signs and height and weight. D. The nurse observes the general appearance of the child. E. The nurse asks questions about the child's history.

A. The nurse finds out the reason for the child's visit to the health care setting. B. The nurse interviews the child's caregiver. E. The nurse asks questions about the child's history.

Where is the point of maximal impulse (PMI) found in a 5-year-old child? A. the fourth intercostal space B. the third intercostal space C. the clavicle D. the sternum

A. the fourth intercostal space

The father of a toddler tells the nurse that his child had a fever the previous night. During the assessment, which statement by the father indicates further discussion is necessary regarding temperature measurement? A. "We have an electronic oral thermometer. It seemed to match our child's symptoms of fever better." B. "My mother said she always used a glass thermometer when I was a kid and it was very accurate. Maybe that would be better." C. "I used one of those thermometers that goes in the ear, but I don't think it was accurate." D. "I know rectal temperature is pretty accurate but I didn't see that it was necessary to cause the discomfort of that route."

B. "My mother said she always used a glass thermometer when I was a kid and it was very accurate. Maybe that would be better."

The nurse brings a 2-day-old newborn into the mother's room in the postpartum unit. The mother voices concern that the newborn's hands and feet "look a little blue." Which response by the nurse is best? A. "This condition is known as acrocyanosis. It is normal for a newborn, but I will be sure to let the pediatrician know." B. "This is common for newborns up to several days of age. It happens because of the immature circulatory system trying to get used to being outside the uterus." C. "This is normal for a newborn. You do not have anything to worry about." D. "New moms often worry that something is wrong. Everything is fine."

B. "This is common for newborns up to several days of age. It happens because of the immature circulatory system trying to get used to being outside the uterus."

The nurse is teaching a group of novice nurses how to assess bowel sounds. Which statement will the nurse include in the education? A. "Bowel sounds should be present within the first few days of life." B. "You should auscultate all four quadrants for a full minute each." C. "Hypoactive bowel sounds are expected in a client with diarrhea." D. "Bowel sounds will be audible by the naked ear unless distention is present."

B. "You should auscultate all four quadrants for a full minute each."

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? A. Counsel the new graduate. B. Demonstrate the appropriate technique. C. Applaud the good technique. D. Explain why the technique is incorrect.

B. Demonstrate the appropriate technique.

The mother of a 9-month-old child reports her child's eyes are often crossed. The nurse confirms this during the examination. What action is indicated? A. Document the finding as normal. B. Report the findings to the physician. C. Ask the mother if this was a problem in her other children. D. Explain to the child's mother that this is normal until about one year of age.

B. Report the findings to the physician.

While at school, the client is called to the school nurse's office. The school nurse is performing secondary prevention interventions. Which would the nurse most likely be performing? A. asking the client if he or she likes school B. assessing vision C. asking the client about what he or she usually eats each day D. checking temperature

B. assessing vision

The nurse is examining an 8-month-old infant who just moved to the United States from Japan. What feature would be important to examine on the infant during physical exam? A. eyes B. mouth C. ears D. abdomen

B. mouth

While assessing a 6-month-old, the nurse notes the posterior fontanel (fontanelle) is open. What action should the nurse take next? A. Notify the health care provider. B. Document the finding in the chart. C. Assess the anterior fontanel (fontanelle). D. Review the baby's history.

C. Assess the anterior fontanel (fontanelle).

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? A. Open anterior fontanel (fontanelle) and closed posterior fontanel (fontanelle) B. Open anterior and posterior fontanels (fontanelles) C. Closed anterior and posterior fontanels (fontanelles) D. Closed anterior fontanel (fontanelle) and open posterior fontanel (fontanelle)

C. Closed anterior and posterior fontanels (fontanelles)

When auscultating bowel sounds, which of the following frequencies would the nurse identify as normal? A. Thirty to 40 per minute B. One to two per minute C. Five to 10 per minute D. Sixty per minute

C. Five to 10 per minute

To obtain an accurate heart rate in an infant, what would be most important for the nurse to do? A. Count the pulse rate for 30 seconds. B. Take a radial pulse. C. Take the apical pulse. D. Use an electronic stethoscope.

C. Take the apical pulse.

A nurse is preparing to examine the ear of a 2-year-old child. The nurse would pull the pinna in which direction? A. forward B. up C. down and back D. up and back

C. down and back

A new client arrives for a first visit to the pediatric clinic. The nurse will prioritize which step in this appointment? A. interviewing the caregiver B. recording the health history C. obtaining biographical data D. determining the chief complaint

C. obtaining biographical data

When questioning a 15-year-old about his health history, what would be an appropriate way for the nurse to ask about the child's drug history? A. "Have you smoked cigarettes?" B. "Have you smoked crack before?" C. "Have you had alcohol at parties before?" D. "Have you heard that some teens like to smoke? Have you tried this?"

D. "Have you heard that some teens like to smoke? Have you tried this?"

The nurse is auscultating the lungs of a lethargic, irritable 6-year-old boy and hears wheezing. The nurse will most likely include which teaching point if the child is suspected of having asthma? A. "We're going to go take a look at your lungs to see if there are any sores on them." B. "I'm going to hold your hand while the phlebotomist gets blood from your arm." C. "I'm going to have the respiratory therapist get some of the mucus from your lungs." D. "I'm going to have this hospital worker take a picture of your lungs."

D. "I'm going to have this hospital worker take a picture of your lungs."

When obtaining information from a teen concerning the reason for seeking health care, which question would be most important? A. "Do you have any health concerns?" B. "How long have you been ill?" C. "Have you been feeling well lately?" D. "What health concerns are you having?"

D. "What health concerns are you having?"

A 5-year-old child is being seen at the ambulatory care clinic for a well-child visit. The child is hiding behind his mother. What initial action by the nurse is indicated? A. The nurse should encourage the child to act like a big boy and stop hiding. B. Promise to give the child a small toy or sticker if he will stop hiding. C. Ask the child's mother to pick him up and put him on the examination table. D. Allow the child to remain "hidden" during the initial part of the interview.

D. Allow the child to remain "hidden" during the initial part of the interview.

The nurse is obtaining the health history for a 9-year-old child who has been brought to the ambulatory care clinic with reports of a backache. Which initial action by the nurse is most appropriate? A. Ask the child to demonstrate movements involving the back. B. Ask the child's parent about when the parent was first made aware of the discomfort. C. Palpate the child's back while asking the severity of discomfort being experienced. D. Ask the child when the pain started.

D. Ask the child when the pain started.

The nurse is examining an infant who is 4 days old. The nurse puts the infant in a semi-upright position and lets the head fall back (with immediate support). What infant reflex is the nurse testing? A. root B. palmar grasp C. Babinski D. Moro

D. Moro