Chapter 32: Health Assessment of Children

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: A. "I should take blood pressure on a child beginning at age 2 years." B. "I should establish good rapport with the child's parents before beginning an assessment on a child." C. "I should take blood pressure on a child beginning at age 3 years." D. "I should take a temperature using an electronic thermometer beginning at age 3 years."

A. "I should take blood pressure on a child beginning at age 2 years. "When performing assessments, the nurse does not usually take blood pressure on children younger than 3 years. The recommendations are that blood pressure assessment be done at least once during every health care visit on children aged 3 years and older. Children younger than 3 years should have blood pressure assessed if they have a history of prematurity, have congenital heart defect, have a urinary tract infection, take any medications that influence the blood pressure or have increase intracranial pressure. Blood pressure measurement on hospitalized children is taken according to hospital policy no matter what age. The nurse should always establish good rapport with the child's parents. The nurse would use an electronic thermometer to take a temperature on a child who is 3 years.

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 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." B. "New moms often worry that something is wrong. Everything is fine." C. "This condition is known as acrocyanosis. It is normal for a newborn, but I will be sure to let the pediatrician know." D. "This is normal for a newborn. You do not have anything to worry about."

A. "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." Blueness of the hands and feet, known as acrocyanosis, is normal in newborns up to several days of age and results from an immature circulatory system completing the switch from fetal to extrauterine life. This best response explains why the blueness is occurring without using medical terminology and lets the mother know this is expected and normal. The nurse should not dismiss the mother's concern or decide whether the mother should worry about her newborn.

A 4-year-old is ordered to have a hearing test. How should the nurse best prepare the child for this exam? A. Allow the child to play with the tuning fork. B. Explain the procedure to the child. C. Explain that no pain is involved. D. Demonstrate the procedure on the mother.

A. Allow the child to play with the tuning fork. To conduct the Weber test for hearing function the nurse would strike a 500-Hz tuning fork and hold the stem of it against the top of the child's head. The child with normal hearing in both ears will hear the sound equally well with both ears. If the child has an air conduction loss in one ear, the child will hear the sound better in that ear rather than the good ear. The test is used in conjunction with other evaluation tools because if the sound is intensified in one ear, it may mean that there is no hearing perception (i.e., there is nerve loss) in the opposite ear. Explaining and demonstrating the procedure to the child may be important, but developmentally the child needs to be able to see, feel, and hear all equipment being used.

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? A. Ask the caregiver questions and document the answers. B. Have the caregiver sit in a quiet room and fill out a questionnaire. C. Ask the caregiver if he or she can read or if someone is needed to read the questions on the admission form to him or her. D. Have the child read the questions to the caregiver and then write down the answers on the form.

A. Ask the caregiver questions and document the answers. The family caregiver provides most of the information needed in caring for the child. Rather than simply asking the caregiver to fill out a form, it may be helpful to ask the questions and write down the answers. This provides a personal interaction between the nurse and the caregiver. If the caregiver cannot read, the nurse would help with the completion of the form by asking questions and documenting the answers. Children should not be used as interpreters or complete a form. If the child is under the age of 18 it would not be a legal document, and with a child's language skills and comprehension much-needed information could be not obtained.

While examining a child, the nurse notes quiet, soft sounds each time the stethoscope is moved over the child's chest. The nurse knows that these are not breath sounds. What actions should the nurse take? Select all that apply. A. Auscultate with the child sitting up. B. Refer the child for further evaluation. C. Record the location and timing of the sounds. D. Auscultate with the child lying down. E. Conclude this is a grade 3 heart murmur.

A. Auscultate with the child sitting up. B. Refer the child for further evaluation. C. Record the location and timing of the sounds. D. Auscultate with the child lying down. The sounds described are characteristic of a grade 2 heart murmur. The child's heart should be auscultated with the child in two different positions—upright and reclining. Innocent murmurs often disappear when the child's position is changed. Recording the location and timing of the sounds is important to further the evaluation and in determining the type and meaning of the murmur. A child with a heart murmur needs further evaluation by an experienced examiner.

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. Review of systems C. Family profile D. History of past illnesses

A. Details about the fever When the child has an acute problem, it is important to first obtain the chief complaint. This is the reason the child is brought to the health care provider. The nurse would then ask further questions about the onset, the duration, the characteristics and the course of the problem. The family history, history of past illnesses, and a review of the systems would come later in the process of obtaining the health history.

During a routine physical examination of a 13-year-old female the nurse notes the presence of a tender nodule just below the nipple on her right breast. Which action by the nurse is indicated? A. Document the finding as normal. B. Request the teen have a breast ultrasound. C. Request the teen have a mammogram. D. Review the teen's medical record for family history of breast cancer.

A. Document the finding as normal. Adolescent females may have a tender nodule beneath the nipple. This signals the onset of puberty.

A 6-week-old infant is being assessed for vision acuity. What questions should the nurse ask the parents to ascertain adequate vision? Select all that apply. A. Does the baby follow you with her eyes? B. Does the baby have any unusual eye movements? C. Do the parents have any concerns? D. Can the baby focus on a moving object? E. Is there any drainage from the eyes?

A. Does the baby follow you with her eyes? C. Do the parents have any concerns? D. Can the baby focus on a moving object? Newborns should be able to focus on a moving object such as a finger and follow it to the midline. Infants see black and white better than they do colored objects. They seem to see objects that are at a distance of about 8 to 10 inches. The parents should be asked if their infant's eyes follow them as they move around the room. An infant older than 6 weeks should be able to return the parents' smiles. Parents should be asked if they have any reason to think their child has vision difficulty. Unusual eye movements and drainage from the eyes indicate there is a medical problem and not a visual problem.

The nurse is assessing a newborn. The child's mother asks about small pink area on the bridge of the child's nose. What would be the appropriate response by the nurse? A. It's called a salmon nevi or a stork bite. They typically fade over time but may never go away totally." B. "It is called strawberry hemangioma. It usually fades in time, typically by the time the child turns 9." C. "It is called a nevus flammeus. It typically fades over time but may never go away." D. "The medical term for the spot is ecchymosis. It's harmless."

A. It's called a salmon nevi or a stork bite. They typically fade over time but may never go away totally." Light pink macule typically found on the eyelids, nasal bridge, or back of neck are called salmon nevi (or, more commonly, "stork bites"). They usually fade over time, but may never go away completely. An infantile (strawberry) hemangioma is a raised reddish papule made of blood vessels. They recede over time, usually by age 9 years. A nevus flammeus is a dark purple-red flat patch and grows with the child. It is more commonly known as a port-wine stain. Ecchymosis is a purplish discoloration that is more commonly known as a bruise.

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. A. Not speaking clearly B. Speaking loudly C. Running around when spoken to D. Responding inappropriately in conversation E. Not responding when spoken to

A. Not speaking clearly B. Speaking loudly D. Responding inappropriately in conversation E. Not responding when spoken to A high activity level in the child is most likely normal and would not indicate any hearing difficulty. The other choices are all associated with hearing difficulty and would warrant audiometry.

The nurse assesses the heart of a 13-year-old and notes the presence of a fourth heart sound. What would the nurse do next? A. Notify the health care provider B. Assess for pulse deficit C. Document the finding D. Obtain an apical pulse rate

A. Notify the health care provider The presence of a fourth heart sound generally signifies heart pathology. This sound is called a gallop rhythm and is caused by an abnormal filling of the ventricles. This causes increased pressure on the valves. Physiologic splitting is the term when the pulmonary valve closes slightly later than the aortic valve. Murmurs cause the heart to pump with abnormal force. If the heart is struggling a thrill can be felt on the chest wall. The health care provider should be notified of this finding. Pulse measurements help the health care provider in making a diagnosis but the health care provider should be notified first.

The nurse is preparing to measure an infant's temperature with a tympanic thermometer. Which is the correct way to position the device? A. Pull the child's earlobe back and down and point the sensor beam toward the center of the tympanic membrane. B. Pull the child's earlobe back and up, and point the sensor beam toward the center of the tympanic membrane. C. Pull the child's earlobe back and down, and point the sensor beam toward the side of the ear canal. D. Pull the child's earlobe back and up, and point the sensor beam toward the side of the ear canal.

A. Pull the child's earlobe back and down and point the sensor beam toward the center of the tympanic membrane. For a child younger than 3 years, pull the earlobe back and down. Insert the tympanic thermometer gently into the ear canal with the infrared sensor beam directed toward the center of the tympanic membrane rather than the sides of the ear canal.

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. Ask the mother if this was a problem in her other children. C. Document the finding as normal. D. Explain to the child's mother that this is normal until about one year of age.

A. Report the findings to the physician. Persistent strabismus is normal in newborns. If noted after the age of 6 months it should be evaluated by a pediatric ophthalmologist. This will need to be reported to the physician so that the referral can be made.

What is typical of a grade II heart murmur? A. The murmur is soft but easily heard. B. The murmur is soft and hard to hear. C. The murmur is loud without an associated thrill. D. The murmur is loud with an associated thrill.

A. 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 assessing a 5-year-old's oral temperature. Which actions by the nurse indicate knowledge of the procedure? A. The nurse asks the mother if the child has had anything to drink recently. B. The nurse places the thermometer on the child's tongue to ensure accurate measurement. C. The nurse waits to measure the child's temperature 30 minutes after a nebulizer treatment. D. The nurse encourages the child to keep the mouth closed during temperature measurement. E. The nurse asks the child to stop eating long enough for the temperature to be measured.

A. The nurse asks the mother if the child has had anything to drink recently. C. The nurse waits to measure the child's temperature 30 minutes after a nebulizer treatment. D. The nurse encourages the child to keep the mouth closed during temperature measurement. By 5 years of age, the child can hold an electronic oral thermometer in the mouth well enough to obtain a reading. The probe should be placed under the tongue and the child's mouth must remain closed until the device registers the temperature. Oral intake, oxygen administration, and nebulized medications or treatments may affect oral temperature.

Due to casts on both arms, the nurse must measure an 11-year-old client's blood pressure in the thigh. After placing the blood pressure cuff on the thigh, which action by the nurse demonstrates understanding of the procedure? A. The nurse places the stethoscope over the popliteal artery. B. The nurse places the stethoscope over the posterior tibial artery. C. The nurse places the stethoscope over the femoral artery. D. The nurse places the stethoscope over the dorsalis pedis artery.

A. The nurse places the stethoscope over the popliteal artery. The stethoscope should be placed on the artery nearest, but below, the blood pressure cuff.

A nurse is conducting a comprehensive pediatric history of an 8-year-old child. Which data would the nurse likely include? Select all that apply. A. age, name, and date of birth B. allergies to food or medications C. developmental milestones D. foods the child likes to eat E. number of playmates

A. age, name, and date of birth B. allergies to food or medications C. developmental milestones D. foods the child likes to eat A comprehensive pediatric history includes information about the following: identifying or biographic data; reason for seeking care; history of present illness; past medical history including current medications, allergies, immunizations, nutritional practices, and habits and behaviors; family health history; social and environmental history; spiritual history; and a review of systems.

A nursing instructor is teaching students how to assess a newborn and emphasizes the importance of taking femoral pulses. Doing so will help to rule out which condition? A. coarctation of the aorta B. peripheral disease C. pulmonary hypertension D. hypotension

A. coarctation of the aorta When performing an assessment on a newborn, it is important to assess the femoral pulse to rule out coarctation of the aorta. The narrowing, or coarctation, of the aorta causes blood to flow to the upper part of the body but not the lower part. The upper half of the body is warm and perfused while the lower is cool and pale. This diagnosis can also be ascertained by B/P readings. If the reading is lower in the leg than the arm then coarctation should be considered. Hypotension would be determined by B/P measurement, not palpating a pulse. Peripheral disease can be arterial or venous in nature. These would be assessed either from the popliteal or dorsal pulses. Pulmonary hypertension is high B/P in the arteries of the lungs. It could not be determined by palpating a peripheral pulse.

The nurse is examining a child's skin for lesions and rashes. When documenting the findings, which would the nurse include? Select all that apply. A. size B. location C. jaundice D. distribution E. color

A. size B. location D. distribution E. color When assessing the skin for lesions or rashes, the nurse would document the location, size, distribution of the lesions over the body, and distinguishing features of the primary or secondary lesion, including color, shape, raised, craterlike or flat, hard or soft if a mass, and exudate. Jaundice is a discoloration of the skin and is not a characteristic finding of a lesion or rash.

The nurse is examining the genitals of a healthy newborn girl. The nurse should observe which normal finding? A. swollen labia minora B. lesions on the external genitalia C. swollen and red anal area D. labial adhesions

A. swollen labia minora The newborn's labia minora is typically swollen from the effects of maternal estrogen. The minora will decrease in size and be hidden by the labia majora within the first weeks. Lesions on the external genitalia are indicative of sexually transmitted infection. Labial adhesions are not a normal finding for a healthy newborn. A swollen and red anal area would be an abnormal finding.

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? A. Count the respiratory rate for 30 seconds. B. Count after the child stops crying and is comfortable. C. Count abdominal movements. D. Place a stethoscope to count respirations.

B. Count after the child stops crying and is comfortable. Respirations should be assessed when the child is resting or sitting quietly because respiratory rate changes significantly when children cry, eat, or become more active. They also breathe more rapidly when anxious or frightened. Counting respirations for a full minute assures accuracy. Infants' respirations are primarily diaphragmatic; therefore, counting abdominal movements promotes accuracy. Placing a stethoscope to count respirations tends to be seen as invasive by a toddler and will result in movement away or an increase in respirations.

A nurse is performing a health history on a 6-year-old child with asthma. When it comes to identifying if the child is up to date on the immunization schedule, which question would be avoided as it is considered leading? A. Do you have the immunization book for us to review? B. Have you kept the child up to date on all of the immunizations suggested? C. Were there any side effects from the last immunizations? D. When did the child have his/her last immunization?

B. Have you kept the child up to date on all of the immunizations suggested? A leading question supplies its own answer. This question implies that the child should have had the immunizations and perhaps that the parent is a poor caregiver if he or she gives a different answer than yes. Further, the parent may not be aware of all the current immunizations for the child's age and may inadvertently give an incorrect answer. Asking about the last immunizations is appropriate. Offering to review the immunization record is part of anticipatory guidance. It is important to know if the child had any reactions to the last immunizations to determine whether the child should receive that immunization again.

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

B. The nurse asks questions about the child's history. C. The nurse interviews the child's caregiver. D. The nurse finds out the reason for the child's visit to the health care setting. Most subjective data are collected through interviewing the family caregiver and the child. Subjective is the data collected from another source or data that the nurse can not assess, such as pain. No one can feel the pain the client is experiencing. Objective data is information which can be gathered by direct assessment. Getting the necessary information from the caregiver would be a form of subjective data. Taking the vital signs and visual inspection are forms of objective data.

A 14-year-old male adolescent is brought to the clinic by his parent who is concerned the adolescent is developing an excessive amount of breast tissue. The examination confirms that the adolescent has slight enlargement of the breast tissue. What information should be relayed to the adolescent and his parent? A. Hormone therapy may be initiated to resolve the condition. B. This is a normal and transient condition of adolescent males. C. This growth is abnormal but cannot be managed until the adolescent's growth has stopped. D. The adolescent will need to have hormonal levels assessed for the presence of estrogen.

B. This is a normal and transient condition of adolescent males. Breast growth in adolescent males may occur in response to hormonal levels. This condition will self resolve as hormones become more balanced. Therapy and laboratory studies are not indicated at this time.

The nurse is assisting with the physical examination on a sleeping 10-month-old infant being held by the parent against the parent's shoulder. In what sequence would the nurse complete the assessment? A. eyes, ears, nose, mouth; back and extremities; then the head and neck B. back and extremities; head and neck; then the ears, nose, mouth, and eyes C. back and extremities; eyes, ears, nose, mouth; then the head and neck D. head and neck; eyes, ears, nose, mouth; then the back and extremities

B. back and extremities; head and neck; then the ears, nose, mouth, and eyes Data are collected by examination of the body systems. Often the exam for an infant is not done in a head-to-toe manner, as is done with adults, but rather in an order that takes the infant's age and developmental needs into consideration. Because the infant is asleep and held against the parent's shoulder, the nurse would begin by assessing the infant's back and extremities. The infant's eyes would be inspected last to allow the infant to be most comfortable until the end of the assessment. Aspects of the examination that might be more traumatic or uncomfortable for the infant are completed last.

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 which statement? A. "Associated symptoms are important to ask about." B. "Frequency refers to how often the concern happens during the day." C. "Intensity refers to how often the concern occurs during the day." D. "Intensity refers to the kind of the problem."

C. "Intensity refers to how often the concern occurs during the day." Frequency refers to how often the concern occurs during the day. Intensity refers to the kind of problem. Associated symptoms are important to ask about.

A 15-year-old female is being seen for an annual physical examination. The teen asks the nurse if what they talk about will be kept private. What is the appropriate response by the nurse? A. "Until you are 16 years of age you will not be afforded total privacy from your parents with regard to your health care concerns." B. "Privacy is important and I will not share anything we talk about with your parents." C. "There are some things I may need to share with your parents or physician." D. "Since you are 15 there are some things we can keep private if you wish."

C. "There are some things I may need to share with your parents or physician." Teens value privacy. The determination of what may and may not be kept confidential is based on individual state laws. The nurse may need to divulge certain things. It is best to be honest with a teen concerning the privacy of the interview, assessment and care.

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. Inability to articulate the sounds of the letter 'R' and "S" when vocalizing B. Purulent draining from one or both ears associated with pain behaviors C. A delay or lack of clear, understandable speech pattern D. A history of supplemental oxygen use at birth or shortly after birth

C. 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.

The nurse is caring for a child and notes mild cyanosis of the fingertips. Which action will the nurse complete next? A. Notify the primary health care provider. B. Determine the child's heart rate. C. Assess the child's oxygen saturation level. D. Document the finding in the medical record.

C. Assess the child's oxygen saturation level. Cyanosis is a condition where there is decreased hemoglobin in the blood. This decrease in oxygen gives the skin a bluish tone. It usually involves the lips, mouth, and trunk. The nurse would first assess the client's oxygen saturation level and apply oxygen. After assessing the client, the nurse would notify the primary health care provider. Determining the heart rate is not an immediate need, but would be assessed before notifying the provider since there is no indication the client's respiratory status is not stable. Last, the nurse would document the finding in the health record.

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? A. The nurse should weigh the parent on a standing scale and then weigh the parent again while holding the child. B. The nurse should lay the parent on the scale covered with a clean paper and gently hold the child flat against the scale and let go just before reading the weight. C. The nurse should have the child sit on the scale while keeping a hand close to but not touching the child. D. The nurse should ask the parent to lightly hold the child's hands while the child is sitting on the scale.

C. The nurse should have the child sit on the scale while keeping a hand close to but not touching the child. The child who is able to sit can be weighed while sitting. Keep a hand within 1 in (2.5 cm) of the child at all times to be ready to protect the child from injury. Weighing the parent alone and then holding the child will not provide an accurate weight. Accurate weights are needed for medications and treatments. Holding the child's hands will cause a change in the weight and should not be done.

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. checking temperature C. assessing vision D. asking the client about what he or she usually eats each day

C. assessing vision Hearing and vision screenings are examples of secondary prevention in health assessments. These are usually state-or federally-mandated screenings to prevent risk factors of specific diseases.

All infants should have their head circumference measured at health assessment visits. Where should the nurse place the tape measure to obtain this measurement? A. the middle of the forehead through the parietal prominences B. the center of the forehead to the base of the occiput C. just above the eyebrows through the prominent part of the occiput D. the hairline in front to the hairline in back

C. just above the eyebrows through the prominent part of the occiput To measure the circumference of an infant's head, the nurse would measure the largest point across the skull, not including the ears, with a no stretching cloth or paper tape. The tape would be placed at the forehead just above the eyebrows and brought around the head in a taut circle just above the occiput prominence at the back of the head. The measurement is then marked on a growth chart so it can be plotted to assess adequate growth. Each of the other options depicts incorrect placement of the tape for measurement and would not provide a correct measurement of the head.

The registered nurse (RN) will intervene if the unlicensed assistive personnel (UAP) is noted performing which task? A. counting the respirations on a preschool-age client for a full minute B. obtaining an infant's apical pulse while the infant is asleep in the crib C. pulling the earlobe down and back while checking a school-age client's tympanic temperature D. obtaining blood pressure reading on a toddler admitted for recurrent urinary tract infections

C. pulling the earlobe down and back while checking a school-age client's tympanic temperature The RN would intervene if the UAP pulled the earlobe down and back as this is only done when the child is younger than 3 years of age. For a school-age child, the nurse would pull back on the ear. A pulse should be obtained while an infant is resting or asleep to get an accurate reading as the pulse will increase with anxiety. Respirations should be counted for a full minute. Clients younger than 3 years should have their blood pressure monitored if certain risk factors are present, which include recurrent urinary tract infections.

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? A. eyelid blinks in response to touching the cornea with a wisp of cotton B. pupil dilation in response to light C. pupil constriction in response to light D. light of an otoscope reflecting evenly off both pupils

C. pupil constriction in response to light If the pupil constricts (reduces in size) in response to the light, it is confirmation the third cranial nerve is intact; it should not dilate. The eyelid blinking in response to touching the cornea with a wisp of cotton is a test of the blink reflex, but should not be performed in children, as it can be painful and frightening to them. During a Hirschberg test, the light of an otoscope should reflect evenly off both pupils if they are in equal alignment.

When performing a lower extremity assessment which manifestation would be most important for the nurse to evaluate further? A. Gait B. Foot displacement C. Hip abduction D. Limping

D. 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.

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. palmar grasp B. root C. Babinski D. Moro

D. Moro The Moro reflex is stimulated when the infant is semi-upright and the head falls backward. When this happens, the infant responds with symmetrical abduction and extension of the arms, flexion of the thumb, and flexion of the upper limbs. This response should not persist after 4 months of age. The Babinski sign is tested through stimulating the foot/toes. The palmar reflex is tested through the hand/fingers. The root reflex is tested through touch on the corner of the mouth.

When doing a health assessment on a child, the nurse should include a physical assessment. What should the nurse assess first when performing the physical assessment? A. lung sounds B. temperature C. blood pressure D. respirations

D. respirations The assessment of respirations should always be done first. The respiratory rate will change if the child is crying, feeding, or becoming more active. Completing other parts of the physical assessment could influence the count of respirations. When counting respirations, the nurse should be aware that infants use diaphragmatic breathing so the respirations should be counted observing abdominal movements. After 1 year of age breathing changes to thoracic, so chest rise and fall would be used to count respirations. In the sequence of the physical exam, the vital signs would be taken followed by the head-to-toe assessment.

The nurse is caring for a 10-year-old girl and is trying to obtain clues about the child's state of physical, emotional, and moral development. Which question is most likely to elicit the desired information? A. "Tell me about your favorite activity at school?" B. "Do you have a lot of friends at school?" C. "Would you say that you are a good student?" D. "Do you like your school and your teacher?"

A. "Tell me about your favorite activity at school?" A good health history includes open-ended questions that allow the child to narrate their experience. The other questions would most likely elicit a yes or no response.

The nurse is obtaining health information from the parents of a 3-year-old. Which information is of most concern to the nurse? A. "We are renovating an old farmhouse built in the early 1900s." B. "Our children love our new dog. He was a rescue pet so we just finished all of his veterinary visits. C. "My mother lives in those new condominiums in town and babysits for me when I need her to." D. "I am very fortunate to be a stay-at-home mom."

A. "We are renovating an old farmhouse built in the early 1900s." Homes or apartments built prior to 1978 may contain lead-based paint, and children who live there are at an increased risk for the development of lead poisoning. This paint may be exposed during a renovation so there should be further discussion on this topic. Being a "stay-at-home mom," babysitting by grandparents in a new condo, and a well-cared-for pet are not concerns that need to be investigated further.

The nurse is measuring the head circumference of a child during a well-child visit. Until which age should the nurse take this measurement? A. 36 months B. 12 months C. 18 months D. 60 months

A. 36 months Head circumference is measured at every visit until the child is 3 years of age.

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? A. 96.6°F (35.8°C) B. 99.3°F (37.4°C) C. 100.3°F (38.4°C) D. 99.8°F (37.9°C)

A. 96.6°F (35.8°C) 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.

When obtaining a child's health history, the child's demographic data is assessed first. What should the nurse assess next? A. The chief complaint of the child B. How the child feels school is going C. History of illness D. Types of medications the child takes

A. The chief complaint of the child The order of the health history is as follows: demographics, chief complaint, history of the present illness, past health history, a review of the systems, the family health history, developmental history, functional history, and family composition, resources, and the home environment. The chief complaint should be obtained from the parent or guardian and from the child if the child is old enough to verbalize. The child's concern could be different than the parent's. The history of the illness would be the third stage the nurse should assess. That could include the medications the child is currently taking or that could be obtained in the past health history, depending on the child's medical problem.

A nurse is assessing a child's heart sounds and notes a murmur. The nurse documents the murmur as a grade III based which findings? Select all that apply. A. loud B. positive thrill C. no associated thrill D. difficult to hear E. audible with edge of stethoscope

A. loud C. no associated thrill When assessing heart murmurs a grading scale is used to describe the sound of the murmur. A grade III murmur is loud with no associated thrill. A grade 1 murmur is soft and difficult to hear. A grade II murmur is soft and easily heard. A grade IV murmur is loud with an associated thrill. A grade V murmur is loud and audible with the edge of the stethoscope and a thrill is present.

The nurse is assessing the abdomen of a 3-year-old. Which finding should be reported immediately? A. visible peristaltic waves B. active bowel sounds C. rounded abdomen D. tympany over the abdomen

A. visible peristaltic waves Visible peristaltic waves are abnormal and require further evaluation. The other findings are considered normal for the child's age.

A 12-year-old client comes to the clinic for an annual checkup. The nurse needs to take a health history and perform a physical exam. Which method would be the most appropriate when obtaining the client's health history? A. Ask the client to wait outside while the nurse talks with the parent. B. Ask the parent to leave the room. C. Ask the client to fill out the health form. D. Ask the client if it's OK for the parent to be in the room.

Ask the client if it's OK for the parent to be in the room. When obtaining the health history from a young adolescent, give him or her (aged 11 to 14 years) the choice of whether the parent is present during the interview and examination but always allow time to talk alone with the adolescent. Asking the client to wait outside does not acknowledge the client as a person. Asking the parent to leave the room does not give the client a choice in care. Asking the client to fill out the form is not supportive and does not facilitate an exploration of health history.

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. "I'm going to hold your hand while the phlebotomist gets blood from your arm." B. "I'm going to have this hospital worker take a picture of your lungs." DC. "We're going to go take a look at your lungs to see if there are any sores on them." D. "I'm going to have the respiratory therapist get some of the mucus from your lungs."

B. "I'm going to have this hospital worker take a picture of your lungs." The nurse should teach the child using terms a 6-year-old will understand. A chest x-ray is usually ordered for the assessment of asthma to check for hyperventilation. A sputum culture is indicated for pneumonia, cystic fibrosis, and tuberculosis; fluoroscopy is used to identify masses or abscesses as with pneumonia; and the sweat chloride test is indicated for cystic fibrosis.

The nurse is visualizing the ear canal and tympanic membrane of a 14-month-old boy. Which finding would warrant further investigation? A. A pearly pink membrane B. A bubble behind the tympanic membrane C. A mobile tympanic membrane D. Visible bony landmarks behind the membrane E. A gray tympanic membrane

B. A bubble behind the tympanic membrane A bubble behind the tympanic membrane is not a normal finding and indicates a need for further investigation. The other findings are within normal limits.

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? A. Ask the child how much time the mother is with the child. B. Ask the parents to complete a day history. C. Ask the parents how many hours are spent playing with the child each day. D. Ask the parents to name the games the child knows.

B. Ask the parents to complete a day history. The child's current skills, sleep patterns, hygiene practices, eating habits, and interactions with the family can all be elicited by asking a parent to describe a typical day. Day histories are fun to obtain because most parents are eager to describe a day with their child, and information gained this way is surprisingly rich and pertinent, much more so than if parents are just asked how their child sleeps, eats, or plays.

The nurse is assessing the cardiac sounds of a child. Which action would the nurse incorporate into the assessment? A. Auscultate the apical heart rate for 30 seconds and multiply by 2 to obtain the beats/minute. B. Auscultate the heart rate at the point of maximal impulse (PMI) to best interpret the cardiac sounds. C. Auscultate the cardiac sounds over the three prominent valvular areas on the chest. D. Auscultate the heart sounds with the child in both the upright and the prone positions.

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

B. Axillary temperature, femoral pulse, 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.

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? A. Standing height measurement B. Blood pressure recording C. Snellen vision testing D. Observation of walking gait

B. Blood pressure recording Blood pressure measurement begins to be a part of routine assessment at 3 years of age. The preschool E-chart is used for vision screening at this age. Walking gait and standing height measurement will be introduced in future assessments.

When percussing the chest of an infant the nurse hears hyperresonant sounds. What action should the nurse take? A. Obtain an order for a chest x-ray. B. Document the finding. C. Notify the health care provider. D. Obtain an order for a breathing treatment.

B. Document the finding. Percussion of the lung sounds reveals resonance in older children. The sound will be hyperresonant in infants and younger children due to the thinness of the chest wall. Overexpanded lungs will sound hyperresonant in older children. Lungs filled with fluid sound dull in older children and less resonant in younger children. Because these are normal findings in an infant, documentation is the only necessary step the nurse should take.

A young client is admitted with a fever, vomiting, and diarrhea. Upon taking the health history, the nurse asks the client's parent, "What did you do to help your child before coming to health facility?" This is an example of which type of question? A. Compound B. Open-ended C. Closed-ended D. Leading E. Expansive

B. Open-ended This is an example of a open-ended question. It allows for the parent to list all the things she did and not limit the response to only one thing or a "yes" or "no." A closed-ended question only gives a person the choice to answer yes or no so it would not give the information needed to make treatment decisions. A compound question is one where a combination of more than one question is asked in a seemingly single question. This type of questioning only causes confusion and may actually provide incorrect information. A leading question is one that prompts a person to answer in a certain way. An expansive question is not asked to gain information. It is generally asked to start the thinking process.

The parents bring the child for a health exam. After eliciting a chief concern from the parents, the nurse continues gathering information about related and other health concerns. Why is it important for the nurse to ask a second time at the end of the interview if there are other concerns? A. The nurse should help assuage any parental fears before ending the interview. B. Parents will not always reveal their most important concern in the initial minutes of the interview. C. Parents might have concerns that are not so important and should accurately be addressed at the end of the interview. D. Parents always have more than one concern.

B. Parents will not always reveal their most important concern in the initial minutes of the interview. After documenting the chief concern, the nurse should ask about a second or other problem. The nurse should not assume, however, that parents will always reveal their most important concerns in the initial minutes. They also might not speak openly if they do not trust the caregiver. Therefore, it is helpful to repeat the question about a second concern once more at the very end of the interview. Many parents will focus on the reason they brought their child in for care and not other issues with the child. Asking if there are other concerns allows the parent to reveal the other issues that might need care or guidance.

When performing an assessment for scoliosis the nurse asks the child to let both arms hang to the sides. Which observations would be an indication the child requires further screening? Select all that apply A. The elbows fall above the level of the iliac crest. B. The child leans toward one side. C. The elbows are not at the same level. D. The elbows fall below the level of the iliac crest. E. How straight the child is standing

B. The child leans toward one side. C. The elbows are not at the same level. D. The elbows fall below the level of the iliac crest. E. How straight the child is standing When assessing for scoliosis, have the child remove clothing except for undergarments. Ask the child to stand up straight, with feet together and arms at sides. Standing straight with arms at the sides helps to determine uneven posture because it will affect the level of the elbows. The level of the elbows should be assessed in relation to the iliac crests. Normally, elbows fall above the iliac crest. If one or both elbows fall below the iliac crest, or the elbows are uneven, this would be an indication the child will need to be referred for further evaluation by the health care provider.

The nurse is conducting a physical examination of a 5-year-old girl. The nurse asks the girl to stand still with her eyes closed and arms down by her side. The girl immediately begins to lean. What does this tell the nurse? A. The child has poor coordination and poor balance. B. The child warrants further testing for cerebellar dysfunction. C. The child has a negative Romberg test; no further testing is necessary. D. The child warrants further testing for an inner ear infection.

B. The child warrants further testing for cerebellar dysfunction. This indicates a positive Romberg test which warrants further testing for possible cerebellar dysfunction.

The nurse is measuring the vital signs of a group of assigned children. Which action(s) would demonstrate the correct technique? Select all that apply. A. The nurse measures the radial pulse of a 16-month-old child for 1 full minute. B. The nurse listens to the 12-month-old child's heart for about 20 seconds before beginning to count the rate. C. The nurse assesses the child's rectal temperature by gently inserting a lubricated thermometer rectally. D. The nurse auscultates a 7-year-old's apical pulse for 60 seconds. E. The nurse watches the chest rise and fall when assessing the respiratory rate of a 9-month-old child.

B. The nurse listens to the 12-month-old child's heart for about 20 seconds before beginning to count the rate. C. The nurse assesses the child's rectal temperature by gently inserting a lubricated thermometer rectally. D. The nurse auscultates a 7-year-old's apical pulse for 60 seconds. The radial pulse is difficult to palpate accurately in children younger than 2 years of age because the blood vessels lie close to the skin surface and are easily obliterated. Infants and young children are often nervous or fearful, causing the heart rate to elevate; therefore, the nurse will listen to the heart a few minutes before counting the pulse. For children younger than 10 years of age, the nurse will auscultate the apical pulse with the stethoscope for 1 full minute. Infants' respirations are primarily diaphragmatic, so the nurse will count the abdominal movements. The rectal thermometer should be gently inserted and lubricated.

When testing the deep tendon reflexes of a child, a four-point grading scale is used. What would a 1+ result mean for a reflex tested? A. The reflex is hyperactive. B. The reflex is diminished. C. The reflex is brisk. D. The reflex is absent.

B. The reflex is diminished. On the four-point grading scale used in assessing deep tendon reflexes, 1+ indicates a diminished response. With 2+ as average, a grade of 3+ is brisker than average and 4+ is hyperactive. The reflex is absent at a grade of 0. Healthy children should have reflexes 2+. The newborn has reflexes of 3+ and decreases to 2+ by 3 to 4 months of age.

The nurse is completing an assessment on a 2-year-old child. The nurse notes the presence of a raised reddish purple spot on the back of the child's neck. Which statement about this finding is correct? A. Once the child has grown these lesions are usually removed by lasers. B. These lesions will normally fade as the child ages. C. Biopsies of these areas are usually taken once the child is a teen. D. These lesions are associated with the development of Sturge-Weber syndrome.

B. These lesions will normally fade as the child ages. The lesions described are consistent with infantile (strawberry) hemangioma. They are benign and normally fade as the child ages, usually by the age of 9 years. Nevus flammeus (port-wine stain) are associated with the development of Sturge-Weber syndrome.

Which site would be best to use to take the temperature on a 12-month-old infant seen in an emergency room? A. Mouth B. Tympanic membrane C. Axilla D. Rectum

B. Tympanic membrane It is best to always use the least invasive form to take a temperature on an infant or child. The tympanic temperature measures the pulmonary artery temperature and can be measured within seconds by inserting the probe into the ear. Tympanic temperatures can be measured on any child aged 3 months or older. The rectal measurement would be the most invasive technique. There would be very little difference in the accuracy of this measurement and the tympanic one. A 12-month-old infant would not be old enough to hold the probe correctly under the tongue. Generally, oral temperatures are not measured in children younger than 5 years of age. The axilla could be used to take the temperature of a 12-month-old infant but it requires a longer time for the measurement to read. A 12-month-old infant generally does not want to hold still for any longer than necessary.

The nurse is doing an assessment of a 10-year-old girl. She whispers the girl's name from behind the girl. Which cranial nerve is the nurse assessing for? A. V B. VIII C. IV D. III

B. VIII Testing a child's hearing by observing a response to a whisper without a visual clue assesses cranial nerve VIII, the acoustic nerve. Nerve V is the trigeminal nerve and is tested by having the child bite down and by evaluating the corneal reflex and also sensory response with a cotton wisp. Cranial nerve IV is the trochlear and is tested by having the child move the eyes downward and inward. Cranial nerve III is the oculomotor nerve and is testing by evaluating pupil reactivity and the six cardinal positions of gaze.

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

B. fourth 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 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. "I used one of those thermometers that goes in the ear, but I don't think it was accurate." B. "I know rectal temperature is pretty accurate but I didn't see that it was necessary to cause the discomfort of that route." C. "My mother said she always used a glass thermometer when I was a kid and it was very accurate. Maybe that would be better." D. "We have an electronic oral thermometer. It seemed to match our child's symptoms of fever better."

C. "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 should address the comment about use of a glass thermometer. These thermometers should be avoided since they contain mercury, which is toxic if the thermometer would break. Tympanic temperature measurement is dependent on several factors, so accuracy is sometimes questionable. Oral electronic thermometers are generally very accurate. Rectal temperatures are usually not necessary due to being invasive.

The nurse is obtaining a health history on a toddler and asks the parents about their health history, the health history of their other children, and of their parents' health history. The parents ask the nurse why this information is necessary. What is the best response by the nurse? A. "The health history helps us get to know our clients and their families better." B. "I understand your confusion about why these things matter, but it's part of my job." C. "The information can alert us to any disease process that might run in families." D. "This is part of the health form that we are required to complete during an admission."

C. "The information can alert us to any disease process that might run in families. "Obtaining a three-generation health history can help in determining the risk of potential disease processes that have familial tendencies, such as diabetes, heart disease, etc. While the family health history is part of the standard assessment that must be completed, this response does not address the parent's question.

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? A. "They help us understand how well your child is sleeping." B. "They give us information about his muscle strength." C. "These are measurements that tell us how your child is growing." D. "These measurements are important for school entrance."

C. "These are measurements that tell us how your child is growing." Anthropometric measurements include height, weight, and head circumference and can help determine the child's pattern of growth.

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

C. "What health concerns are you having?" When obtaining data from a client, using the appropriate questions is important. Questions should be open-ended to yield the most information. Making questions direct will further refine the information made available. It is important that when interviewing the teen the nurse not promote a condition. Assuming the teen is ill is not appropriate.

A nurse is interviewing a parent regarding the 2-year-old child's recent illness. The nurse would like the parent to elaborate about any symptoms of the illness noticed. Which would be the most effective question for the nurse to ask the parent in this situation? A. "Has your child exhibited a fever and vomiting?" B. "Your child hasn't exhibited a fever, has she?" C. "What symptoms has your child exhibited?" D. "Has your child exhibited any symptoms?"

C. "What symptoms has your child exhibited?" An open-ended question, such as, "What symptoms has your child exhibited?" allows a parent to elaborate, which is what the nurse desires in this case. A closed-ended question, such as, "Has your child exhibited any symptoms?" does not allow the parent to elaborate, and thus would be inappropriate in this case. Compound questions, such as, "Has your child exhibited a fever and vomiting?" should be avoided because the information they elicit is often inaccurate and must be clarified. Likewise, leading questions, such as, "Your child hasn't exhibited a fever, has she?" should be avoided.

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. 33 B. 28 C. 23 D. 32

C. 23 The formula used to calculate the English version:(Weight in pounds X 703) ÷ (height in inches X height in inches). The correct calculation equals 23.

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: A. 1-week recall. B. 12-hour recall. C. 24-hour recall. D. 3-day recall.

C. 24-hour recall. 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.

The nurse obtains a rectal temperature for an 11-month-old infant. Which action will the nurse perform? A. Continue advancing the probe if resistance is felt. B. Explain the procedure to the child. C. Apply water-soluble lubricant to the probe. D. Insert thermometer 1.5 inch (3.75 cm).

C. Apply water-soluble lubricant to the probe. Applying a lubricant to the thermometer probe will help prevent pain or damage to the rectum. The correct distance to insert a rectal thermometer is no more than 1 in (2.5 cm). Inserting the probe too far can damage or perforate the rectal mucosa. An 11-month-old infant is too young to understand explanation of procedures. If resistance is felt, the nurse should not continue advancing the thermometer probe.

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. Palpate the child's back while asking the severity of discomfort being experienced. B. Ask the child's parent about when the parent was first made aware of the discomfort. C. Ask the child when the pain started. D. Ask the child to demonstrate movements involving the back.

C. Ask the child when the pain started. When beginning the interview, it is best for the nurse to ask the child about the health concern. If additional information is needed, the nurse can subsequently consult the parent. Palpating the back and asking the child to demonstrate movements takes place during the examination portion of the appointment and not the health history portion.

A 14-year-old female has been brought to the pediatric ambulatory care clinic for a "sports physical" by her mother. The teen tells the nurse she does not want to have her mother present during the examination. What action by the nurse is most appropriate? A. Talk with the teen and her mother together to ask for each to sign a consent waiver for this request to be granted. B. Ask the physician for permission to proceed with the teen's request. C. Ask the teen's mother to wait in a separate area nearby until the physical examination has been completed. D. Explain to the teen that since she is under the age of 16 she must be examined with a parent in attendance.

C. Ask the teen's mother to wait in a separate area nearby until the physical examination has been completed. Teens may be modest and uncomfortable having a physical examination in front of their parents. When possible, requests by teens for privacy should be granted.

When assessing the eyes of a toddler, the nurse notes the sclera shows above the pupil. Based on this finding what action should the nurse take? A. Document the finding as normal. B. Instruct the mother on eye muscle exercises. C. Report the finding to the health care provider. D. Refer the child to an ophthalmologist.

C. Report the finding to the health care provider. When assessing the eyes, asses that no sclera shows above the pupil. If it does this is termed "sunset sign." It is a possible indication of increased intracranial pressure or trisomy 21. This finding is abnormal and should be reported to the health care provider. Documenting the finding as normal would be incorrect because the finding is abnormal. The nurse would not refer the child to the ophthalmologist without orders from the health care provider. Eye muscle exercises are not warranted in this situation.

The nurse is assessing the heart rate of a healthy 13-month-old child. The nurse knows to auscultate which site to obtain an accurate assessment? A. brachial pulse B. radial pulse C. apical pulse at the third or fourth intercostal space D. apical pulse at the fourth or fifth intercostal space at the midclavicular line

C. apical pulse at the third or fourth intercostal space For children younger than 2 years of age, the nurse should auscultate the apical pulse with the stethoscope at the point of maximum intensity just above and outside of the left nipple at the third or fourth intercostal space. The radial pulse is difficult to palpate accurately on children younger than 2 years of age because the blood vessels lie so close to the skin surface and are easily obliterated. The brachial pulse is not the best point of auscultation. The point of maximum intensity (PMI) is heard best at the fourth or fifth intercostal space at the midclavicular line beginning around 7 years of age.

During the physical examination, the nurse notes a positive Kernig and Brudzinski sign. The nurse interprets these findings to suggest which condition? A. auditory problems B. visual impairment C. meningeal irritation D. organic heart murmur

C. meningeal irritation A positive Kernig and Brudzinski sign are indicative a meningeal irritation and are not associated with auditory or visual problems or heart murmurs.

The nurse begins the physical exam to obtain the child's vital signs. Which would the nurse assess first? A. temperature B. pulse C. respirations D. blood pressure

C. respirations The child's respirations are measured first before any other measurements that may affect the rate.

The nurse is beginning a health history with a 3-year-old child. Which question would the nurse ask the mother first? A. "Is your child ill in any way?" B. "Tell me about your child." C. "Has your child been ill in the past?" D. "Do you have any concerns about your child?"

D. "Do you have any concerns about your child?" The most appropriate question to begin a health history is open-ended. This type of question allows the parent to elaborate on the health of the child. Close-ended questions such as asking if the child has been ill or if the child has been ill in the past limit the amount of information learned for the history. Expansive statements such as "tell me about your child" are too vague.

An anal fissure is observed as the nurse completes a health assessment on an 8-year-old child. What question is most important for the nurse to ask the child? A. "Do you have any bleeding when having a bowel movement?" B. "Can you describe the pain you are having? C. "Have you have any rectal itching at night?" D. "How often do you have a bowel movement?"

D. "How often do you have a bowel movement?" In children, the rectum should be inspected for any protruding hemorrhoids or fissures. Fissures may signify chronic constipation, intra-abdominal pressure, or sexual maltreatment. Rectal itching at night might indicate the presence of pinworms. Bleeding and pain are symptoms of the problem, but do not determine the cause.

The nurse is preparing to assess the internal ear structures of a 3-year-old. The child is resistant to the otoscope. How should the nurse respond? A. "Come, sit on this pretty, little red chair." B. "May I please look inside your ears?" C. "Please sit still so I can see inside your ears." D. "Let's see if I can find some puppies or kittens."

D. "Let's see if I can find some puppies or kittens." The nurse should try to gain the youngster's cooperation by playing a funny pretend game using the "puppies or kittens" to engage the child. It is more likely the preschool-age child would prefer to sit on a parent's lap even though a red chair was offered. Politely asking the child to sit still is respectful but not likely to gain cooperation. Asking permission to look into the child's ear is an invitation for the young preschool-age child to answer "no."

Blood pressure monitoring becomes part of the routine health assessment at what age and older? A. 4 years B. 2 years C. birth D. 3 years E. 1 year

D. 3 years Blood pressure monitoring becomes part of the routine health exam at age 3.

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? A. Initiate a nasogastric tube. B. Call poison control. C. Determine the type of ingestion. D. Administer activated charcoal.

D. Administer activated charcoal. 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.

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. Children may be shy when at the physician's office. To allow the child the opportunity to initially be "invisible" may be beneficial to help the child become acclimated to the surroundings. Telling the child to act like a big boy is not indicated and may "shame" the child and hinder the development of rapport between the nurse and the child. Eventually the child's mother may need to place him on the examination table but this should not be the initial action by the nurse. Promise of a small token may not work and should not be used at this time.

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

D. 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 nurse is examining a child and asks the child to show all of the teeth. For which cranial nerve would the nurse be testing? A. cranial nerve II B. cranial nerve IV C. cranial nerve V D. cranial nerve VII

D. cranial nerve VII The nurse would be testing to see if cranial nerve VII was intact. This is the facial nerve and can be tested by asking to see a child's teeth, or having the child smile or lift an eyebrow. In infants facial symmetry would be assessed. Cranial nerve V is tested to determine the muscles of mastication and sensation of light touch on the face. Cranial nerve II assesses the optic nerve. Cranial nerve IV is assessed by having the child follow the light through the six cardinal positions of gaze.

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: A. refer for further evaluation. B. educate the parent about the abnormal finding. C. teach parent to have child wear hard-soled shoes. D. document as a normal finding.

D. 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.

A nurse assesses the skin of a child and documents evidence of plethora. Which finding did the nurse observe? A. round flat lesions on the neck B. bluish coloration of lips and nail beds C. black and blue areas on the skin D. redness of the cheeks and lips

D. redness of the cheeks and lips Plethora is used to describe redness of the skin, especially the cheeks and lips. Cyanosis refers to the bluish discoloration of the skin and mucous membranes. Macules are round flat lesions. Ecchymoses are large, diffuse areas of black and blue color.

The nurse prepares to examine a 4-year-old boy. How would the nurse proceed? A. Examine the child's extremities first and then the chest. B. Examine different sections of the body at various times. C. Examine the child's chest and then go to the head and down. E. Examine the child's head and work down to the child's toes.

Preschoolers or young children should be examined starting from their head and working down all the way to their toes for a thorough exam. In infants and young children, the examination starts with the chest and then proceeds from head to toes.

The nurse is beginning the examination of a 4-month-old infant. She takes the infant from the mother's arms to do the exam. Where should the nurse place the infant for the exam? A. in the crib facing the mom B. in the nurse's own arms C. in the crib on the infant's back D. in the child treatment room

A. in the crib facing the mom When performing an exam on an infant, the nurse should place the infant in a position so that the parent is in view at all times. This is supportive and comforting to the infant. The other choices do not keep the parent in view.

When preparing to examine a 2-year-old child, which action by the nurse will best establish rapport? A. Perform the examination prior to obtaining the health history. B. Ask to hold the child prior to performing the examination. C. Bend down to the child's eye level to establish contact. D. Give the child a small toy to play with.

C. Bend down to the child's eye level to establish contact. Making eye contact with the child is beneficial to establishing rapport prior to the examination. Two-year-old children may not appreciate being held by a stranger. The parents should be allowed to hold the child as much as possible during the examination to relay a sense of security to the child. A toy may be appreciated by the child, but it does not promote a therapeutic rapport for the examination.

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? A. "How many siblings does your infant have?" B. "Why did you bring your infant to the clinic today?" C. "What is your infant's date of birth?" D. "Are there any acute or chronic illnesses in your infant's history?"

B. "Why did you bring your infant to the clinic today?" The chief concern deals with the reason the parent brought the child to the health care agency at this time. Asking "why did you bring your infant to the clinic today" addresses this concern. No other question addresses this concern.

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? A. Adolescence B. Infancy C. Preschool age D. School age E. Young adulthood

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

When assessing symptoms such as rashes, pain, or lesions, what would be included in the location factor of the symptom? A. color B. amount C.. quality D. localized or generalized

D. localized or generalized When assessing symptoms such as pain, rashes, or lesions, the location must be assessed for local or generalized. Pain should also be assessed for deep, superficial, or radiating. The other choices describe the quality and quantity of the symptom.

A 15-year-old client tells the nurse about being worried that something is wrong because the left breast is bigger than the right breast. What is the best response by the nurse? A. "As your breasts continue to develop it is not unusual to have one breast larger than the other." B. "I am sure it must be concerning to you. I will let your health care provider know about the difference in the size." C. "Let's ask if your mother has always noticed the difference in your breast size." D. "Are you taking any kind of medication over the counter, like anabolic steroids or weight loss pills?"

A. "As your breasts continue to develop it is not unusual to have one breast larger than the other." Breast development may begin as early as age 8 but starts by age 13 in most clients. Breast development then continues in a characteristic, but usually asymmetric pattern, with one breast larger than the other throughout the lifespan.

The nurse is performing an admission assessment on a 12-year-old who suffered a head injury in a motor vehicle accident. Which finding will alert the nurse that the client is demonstrating complications from the accident? A. The child's pulse rate is 90 beats per minute and the respiratory rate is 22 breaths per minute. B. The nurse brings an ink pen toward and away from each eye and notes the pupil dilating as the object moves closer. C. The nurse notes waxy cerumen that is soft and an orangish-brown color when assessing the ear canal. D. The child is able to rate his pain at a 5 on a scale of 0 to 10 when describing his headache.

B. The nurse brings an ink pen toward and away from each eye and notes the pupil dilating as the object moves closer. The eyes demonstrate accommodation, or focusing at different distances, if the pupil constricts as the object moves closer; dilating would indicate a possible neurologic issue. Normal vital signs for a school-age child include a pulse of 60 to 100 bpm and a respiratory rate of 14 to 22 breaths per minute. Being able to rate pain shows intact neurologic status. Cerumen lubricates and protects the external ear canal and is normally orangish-brown in color.

A 4-year-old child is brought to the clinic by the parent, who reports the child is experiencing ear pain. How would the nurse most likely examine the child's ears? A. Grasp the pinna and pull up and back. B. Grasp the pinna and pull forward. C. Grasp the pinna and pull down and back. D. Grasp the pinna and look inside.

A. Grasp the pinna and pull up and back. When examining the ear of a child under 3 years of age, the nurse would pull the pinna down and back. In a child over 3 years old the ear is examined by pulling the pinna up and back. This straightens the ear canal so that the tympanic membrane can be visualized.

The nurse is conducting a physical examination of a 10-year-old child. The nurse whispers the child's name from behind the child so that the child does not see the nurse's lips moving. Which cranial nerve is the nurse assessing? A. VIII B. IV C. III D. V

A. VIII Testing a child's hearing by observing a response to a whisper without a visual clue assesses cranial nerve VIII, the acoustic nerve. Nerve V is the trigeminal nerve and is tested by having the child bite down and by evaluating the corneal reflex and also sensory response with a cotton wisp. Cranial nerve IV is the trochlear and is tested by having the child move the eyes downward and inward. Cranial nerve III is the oculomotor nerve and is testing by evaluating pupil reactivity and the six cardinal positions of gaze.

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

A. down and back The nurse should pull the pinna of the ear down and back for a child younger than age 3 years to help straighten the ear canal. For a child older than age 3 years, the pinna is pulled up and back.

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 will be audible by the naked ear unless distention is present." 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 should be present within the first few days of life."

B. "You should auscultate all four quadrants for a full minute each." During assessment, the nurse should auscultate each quadrant for a full minute when assessing bowel sounds. Therefore, the nurse would include this statement in the teaching. The other statements are inaccurate. Hyperactive bowel sounds are often heard in clients with diarrhea. Bowel sounds should be present within a few hours of life. Bowel sounds are not generally audible with the naked ear.

The nurse is interviewing an adolescent. What should the nurse recognize as an important aspect of interviewing the adolescent? A. Adolescents should be asked if they would like a peer in the room during the interview. B. Adolescents will share more about themselves in a private conversation. C. Adolescents will talk more openly if their caregiver is in the same room. D. Adolescents will not likely share information related to sexual relationships or to use of substances.

B. Adolescents will share more about themselves in a private conversation. All children need the opportunity to actively participate in the health history and assessment process. Adolescents may not feel comfortable addressing health issues, answering questions or being examined in the presence of parents or caregivers. Interviewing them in private often encourages them to share information that they might not contribute in front of their caregivers. Assuring the adolescent that anything shared or discussed will be confidential allows him or her to better discuss sexual needs or use of substances. Adolescents also would rather not have a peer present because they do not want to be seen as different from their peers and there is also the issue of confidentiality.

A nurse in a pediatrician's office is assessing a 4-year-old child. What assessment techniques will the nurse use with a preschool-age child? Complete the following sentence(s) by choosing from the lists of options. To improve the assessment process with a preschool-age child, the nurse will Select... A. set firm rules B. involve the child in the assessment C. have the child sit on the parent's lap Select... A. allow the child to play with safe medical equipment B. direct all questions to the parents C. perform most invasive procedures first

B. involve the child in the assessment A. allow the child to play with safe medical equipment Preschool-age children like to think of themselves as "big kids." They want to be involved during the assessment. The nurse should ask simple questions and provide choices such as "should I look in your mouth first or your ears?" This makes the child feel that they have some control, and the child may be more cooperative during the examination. Allowing the child to play with safe equipment shows the child that the equipment is safe and not painful. The nurse should not set firm rules; this will not elicit cooperation or build rapport with a preschool-aged child. The child should have a choice to sit by themselves or sit on their parent's lap. Allowing the client to make choices provides them with some control and will most likely promote cooperation.The nurse should involve the child in the assessment by asking simple questions; this builds trust and rapport. The nurse should perform the most invasive procedures at the end of the assessment.

The nurse is conducting a skin assessment of a newborn. The examination reveals a light pink macule on the back of the neck. The nurse understands that this is a normal variation and is most likely which type of birthmark? A. purpura B. salmon nevus C. nevus flammeus D. petechiae

B. salmon nevus A light pink macule on the back of the neck is a salmon nevus or "stork bite." A nevus flammeus (port wine stain) is dark purple-red. It is a flat patch that grows with the child. Petechiae are pinpoint reddish macules that do not blanch when pressed. Purpura are large purple macules created by bleeding under the skin.

The nurse is performing an assessment on a teen's clavicle strength. The teen is asked to shrug and raise the shoulders while the nurse applies gentle pressure to them. When documenting the findings, this should be identified as an assessment of which cranial nerve? A. cranial nerve X B. cranial nerve VII C. cranial nerve XI D. cranial nerve IX

C. cranial nerve XI Test shoulder strength and the function of cranial nerve XI in the older child by requesting that the child shrug the shoulders while you apply downward pressure. Cranial nerve VII is responsible for the tongue and facial movements. Cranial nerve IX is responsible for swallowing and salivation. Cranial nerve X is responsible for speech and swallowing.

The nurse is preparing to see a 14-month-old child and needs to establish the chief purpose of the visit. Which approach with the parents would be best? A. "Is your child feeling sick?" B. "Has your child been exposed to infectious agents?" C. "What is your chief complaint?" D. "What can I help you with today?"

D. "What can I help you with today?" Asking "What can I help you with?" is very welcoming and allows for a variety of responses that may include functional problems, developmental concerns, or disease. Asking about the chief complaint may not be clear to all parents. Asking if the child feels sick will most likely elicit a yes or no answer and no other helpful details. Asking whether the child has been exposed to infectious agents is unclear and would not open a dialogue.

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? A. Immunization record B. Recent or past hospitalizations C. Coping strategies of the child D. Past accidents the child was involved in

A. Immunization record 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 preparing to assess the abdomen of a preschool-aged child. Which technique should the nurse use first? A. Inspection B. Auscultation C. Palpation D. Percussion

A. Inspection To assess an abdomen, first inspect the surface for symmetry and contour. After inspection, the nurse should auscultate for bowel sounds. The examination concludes with percussion and palpation.

The nurse is obtaining a functional history during an admission assessment of a 12-year-old child. Which questions would be appropriate for the nurse to ask during this part of the assessment? Select all that apply. A. "Do you wear a seat belt any time you are a passenger in a car?" B. "Do you use a computer or a smartphone?" C. "Are your parents married?" D. "Do you know if your family has a history of any heart problems?" E. "Can you tell me if you play any sports or participate in any physical activities?"

A. "Do you wear a seat belt any time you are a passenger in a car?" B. "Do you use a computer or a smartphone?" E. "Can you tell me if you play any sports or participate in any physical activities?" The functional history should contain information about the child's daily routine. Questions such as the amount of physical activity, car safety, and use of computers and smartphones (including the amount of time on these devices) are included in this assessment. Asking about heart problems is included in the family history assessment, and asking about parents is included in the family composition assessment.

The nurse collects a client history including biographical data regarding the child being admitted. Which responsibility is most important related to the data collected? A. This information is part of the legal record and should be treated as confidential. B. The information collected such as food likes/dislikes and eating habits, should be relayed to appropriate departments in the health care setting. C. Documentation of the information collected should be done as soon as these data are gathered. D. The data need to be shared and communicated to the medical and nursing staff.

A. This information is part of the legal record and should be treated as confidential. Obtaining a client history—including biographical data (e.g., identifying information about the child, the child's name, address, and phone number, as well as information about the caregiver)—is part of the legal record and should be treated as confidential. Information gathered during the interview should be documented as soon as possible so all members of the interdisciplinary team can participate in the care. All allergies, foods, and food dislikes should be relayed to the appropriate departments but this information is not part of the client demographics.

The nurse is preparing to perform a physical examination of a toddler. Which is the preferred location to complete the assessment? A. with the child lying on the examination table with the caregiver right beside the child B. with the child sitting on the examination table with the caregiver outside the examination room C. with the child seated on the caregiver's lap D. with the child sitting on the examination table making eye contact with the caregiver

C. with the child seated on the caregiver's lap Allow some freedom of movement when possible; the child may stand between the seated caregiver's legs or sit on the lap of the caregiver. Lying on the examination table with the caregiver right beside the child would be the preferred location for an infant. Sitting on the examination table with eye contact would be the best location for a school-aged child. Sitting on the examination table with the caregiver outside the room would be appropriate with adolescents.