Chapter 34: Child Health Assessment

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?

"What symptoms has your child exhibited?"

The nurse is performing a health history on a 6-year-old who is having trouble adjusting to school. Which question would most likely elicit valuable information?

"What are your new classmates like?"

A nursing instructor is teaching about taking a health history and how to elicit a chief concern. The instructor realizes a need for further education when a student makes with statement?

"Intensity refers to how often the concern occurs during the day."

A 14-year-old boy has come to his primary care physician's office for a routine well-child visit with his parent. Which statement by the parent should the nurse prioritize for further investigation after noting the father has a history of alcohol use disorder?

"Our next door neighbor is older than my son, and he drinks when they hang out together."

The parents of a 2-day-old girl are concerned because her feet and hands are slightly blue. How should the nurse respond?

"This is normal; her circulatory system will take a few days to adjust."

The nurse is caring for an infant involved in a motor vehicle accident. The nurse uses the modified coma scale for infants and notes the following: spontaneous eye opening, moaning to pain, and withdraws to pain. Which score will the nurse record?

10 The modified coma scale for infants may be used for infants instead of the Glasgow coma scale. The scale is broken down into eye opening, verbal response, and motor response. The infant's score is 10 based on these categories. The remaining answer choices are incorrect.

At what age is measuring occipital head circumference in a child discontinued?

24 months

The nurse is visualizing the ear canal and tympanic membrane of a 14-month-old boy. Which finding would warrant further investigation?

A bubble behind the tympanic membrane

The nurse is conducting the Denver Articulation Screening with a 5-year-old girl to assess her speech. Which of the following should the nurse do while conducting this exam?

Convey the impression that there are no right or wrong answers

A nurse is assessing a 3-year-old child in the local health clinic. The child has a persistent cough on examination. Based on the age of the child, which muscle would the nurse view to assess respiratory status?

Abdominal muscle

A 4-year-old is ordered to have a hearing test. How should the nurse best prepare the child for this exam?

Allow the child to play with the tuning fork.

As part of a class assignment a nursing student will teach fellow classmates how to conduct a physical assessment on an infant. What priority information should the student teach?

Assess the heart and lungs first.

The nurse preceptor observes a novice nurse perform a pediatric assessment. Which action by the novice nurse will the nurse preceptor determine is a normal variance to assessment technique when compared to the assessment of an adult patient?

Assessing the abdomen before assessing the head and neck

The nurse is assessing symptoms in a 6-year-old child. The nurse knows that symptom assessment includes questioning the child and parent regarding which of the following? (Select all that apply.)

Associated factors or symptoms Location of symptoms Setting in which symptoms occur Aggravating or relieving factors

A nurse is performing a physical examination on a newborn. Which assessment should she include?

Axillary temperature, femoral pulse, head circumference

The nursing student is preparing to explain the appropriate steps for assessing an infant. The instructor determines the student's presentation is successful after illustrating which location as appropriate for obtaining an apical pulse?

Between the sternum and the left nipple

The nurse is interviewing the mother of a child who is at the local clinic. When asked why she brought her toddler in today, she replies that he has been running a fever and coughing a lot since last weekend. This information would be noted in the chart as what data?

Chief complaint

Parents bring a toddler age 19 months to the clinic for a regular checkup. When palpating the toddler's fontanels, what should the nurse expect to find?

Closed anterior and posterior fontanels

The nurse prepares to perform a head-to-toe exam on an infant. Which nursing action will the nurse perform?

Count the infant's respirations for a full minute

The charge nurse observes a new graduate nurse assess the cremasteric reflex in an 8-month-old boy. The new graduate nurse strokes the lateral aspect of the thigh. Which action should the charge nurse take?

Demonstrate the appropriate technique.

The pediatric nurse is caring for an 8-month-old infant and notes that the infant sucks half-heartedly while drinking a bottle of formula. Which action by the nurse takes priority?

Determine if this is a change from a previous behavior

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?

Determine the type of ingestion 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 toddler is brought to the pediatric clinic by the caregiver because the child "doesn't feel well." As the nurse interviews the caregiver about why the client is there, which goal is the nurse prioritizing at this point?

Determining the chief complaint

When assessing heart sounds on a high school athlete the nurse hears a "lub d-dub" sound which is associated with inspiration. What should the nurse do next?

Document the findings as normal With inspiration and the resulting increase or pressure in the lungs, the pulmonary valves close slightly later than the aortic valve. This causes a variation in heart sounds. This is termed physiologic splitting and is heard as a "lub d-dub" sound. As long as this is associated with inspiration this is a normal finding. If splitting were to be consistently heard this would indicate difficulty with the pulmonary valve closing and suggests pathology. Because this is a normal finding no referrals need to be made.

The nurse is performing a physical exam on a 3-year-old boy. What method would the nurse use to perform the exam?

Examine the child's head and work down to the child's toes.

A nurse is assessing a Babinski reflex in a 2-day-old newborn. Which finding by the nurse would indicate a positive finding?

Fanning of the infant's toes

While auscultating the heart of a 5-year-old child, the nurse notes a murmur that is soft and quiet and heard each time the heart is auscultated. The nurse documents this finding as what grade?

Grade 2

A 4-year-old girl reports having ear pain. To examine the child's ear, how should the nurse proceed?

Grasp the pinna and pull up and back.

The mother tells the nurse her daughter has come to the clinic today because she has been having stomach pain. What should the nurse ask the mother? Select all that apply.

Has the child had fever? Where is the pain located? How long has she had pain? When was the last bowel movement? Have you given her any medication for the pain?

The nurse is conducting a physical assessment on a 2-year-old. What steps are important for the nurse to incorporate in this examination? Select all that apply.

Have parents remove the clothing. Allow play with the equipment being used. Stand on the scale for height and weight.

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?

Have you kept the child up to date on all of the immunizations suggested?

When assisting with the physical exam of a 1-year-old child, the nurse notes the following findings. Which finding would be concerning to the nurse?

Heart rate of 80

The nurse asks the parents of a child about the family health history. The father asks the nurse why she needs his information. The nurse would explain that the family health history is gathered for what reason?

Identifying risk factors in families decreases the child's risk of developing the same conditions or health problems.

A nurse is taking a health history on a new family at the pediatric clinic. Which information is the priority information to gather for a complete history database?

Immunization record

The nurse is teaching the student nurse how to perform a physical assessment based on the child's developmental stage. Which statement accurately describes a recommended guideline for setting the tone of the examination for a school-age child?

Include the child in all parts of the examination; speak to the caregiver before and after the examination.

The nursing instructor is monitoring the nursing students as they role-play conducting assessments on children and their caregivers. The instructor determines the session is successful after witnessing the students collect the necessary subjective data during which portion of the assessment process?

Interviewing the child's caregiver

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

Limping

A full term gestation infant weighed 8 pounds 1 ounce (3.7 kg) at birth. The baby's weight at the 4-month-old well-child visit is 10 pounds 2 ounces (5 kg). Which intervention should the nurse implement first?

Notify the healthcare provider of the findings.

A young client is admitted with a fever, vomiting, and diarrhea. Upon taking the health history, the nurse asks the client's mother, "What did you do to help your son before bringing him to health facility?" This is an example of which type of question?

Open-ended

A nurse is packing a bag with all of the equipment she will need to perform a complete physical assessment at a client's home. What will the nurse need? Select all that apply.

Ophthalmoscope Stethoscope Thermometer Tongue depressor

The nurse should instruct the pregnant client not to receive which vaccine?

Oral polio

After eliciting a chief concern from a client, a 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?

Parents will not always reveal their most important concern in the initial minutes of the interview.

A 10-year-old has braces on her teeth. What is most important for the nurse to assess when inspecting the mouth?

Pinpoint ulcers on the gums

The pediatric nurse is caring for a group of children of various ages. When assessing the children's blood pressures (BP), which child's reading should be reported to the health care provider? Select all that apply.

Preschooler with BP 70/42 mmHg Adolescent with BP 142/90 mmHg

The nurse is performing an examination of the eyes of a 7-year-old girl. Which finding would indicate that the third cranial nerve is intact?

Pupil constriction in response to light

A parent has brought the child into the clinic for a routine health assessment. The parent asks when routine screening for back symmetry will begin. Which response by the nurse is most accurate?

School age

To obtain an accurate heart rate in an infant, what would be most important for the nurse to do?

Take the apical pulse.

When obtaining a child's health history the child's biological data is assessed. What is the next thing to assess in the child's history?

The chief complaint of the child

Where is the point of maximal impulse (PMI) found in a 5-year-old girl?

The fourth intercostal space.

The nurse is working at a pediatric clinic and is preparing an infant for a well child check-up and immunizations. How should the nurse prepare the infant for the visit?

The infant should be totally unclothed during the physical examination.

The nurse is assessing the Babinski sign in a 3-day-old infant. What is a normal response?

The infant's toes fan and the big toe has dorsiflexion.

What is typical of a grade II heart murmur?

The murmur is soft but easily heard.

The nurse is weighing a 20-month-old who is in the clinic for a well-child visit. Which action by the nurse would be most appropriate for weighing this child

The nurse should have the child sit on the scale while keeping a hand close to but not touching the child.

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?

The reflex is diminished.

The mother of 2-year-old triplets is anxious and worried because one of the trio does not seem to be developing at the same rate as the other two. Which assessment finding would lead the nurse to question the need for further diagnostic testing for this child?

The tops of her ears are below the corners of her eyes.

A nurse is assessing the fontanelles of a crying newborn and notes that the posterior fontanelle pulsates and briefly bulges. What do these findings indicate?

These are normal findings.

The nurse is taking the health history for a toddler in the emergency department. The child's mother informs the nurse that the toddler has been vomiting for the last 3 days, has a history of asthma, and was hospitalized with pneumonia and a urinary tract infection 6 weeks ago. What would the nurse recognize as is the client's chief concern/complaint?

Vomiting

A mother tells the nurse at the clinic she did not bring her child to have his scheduled immunization because the child had a cold. What symptoms are important for the nurse to teach the mother about contraindications for immunizations? Select all that apply.

Wheezing The child has 102ºF (38.9°C) fever 100ºF (37.8°C) fever for 3 days

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?

coarctation of the aorta

An 18-month-old has fanning of the toes and dorsiflexion of the big toe seen on physical exam. Based on this finding the nurse should:

document as a normal finding.

The nurse is performing a respiratory assessment on a black adolescent experiencing a sickle-cell crisis. Where is the best place for the nurse to check for cyanosis on this client?

mucous membranes

A nurse has just performed an assessment on a 12-year-old client and has identified a distended bladder that has a hyper-resonant (low, hollow) sound. Which technique did the nurse use to identify this sound?

percussion