HEALTH ASSESSMENT EXAM 3
Depressed fontanel may indicate
dehydration
Edinburgh Postnatal Depression Scale
developed to assist primary care health professionals to detect whether mothers are suffering from postnatal depression
The nurse suspects respiratory distress in a newborn infant who exhibits which of the following?
sternal retractions
APGAR
- Done at 1 and 5 minutes after birth (followed by 5 min increments in score <7) - Max score of 10 - Generalized skin color (Appearance) - Heart rate (Pulse) - Reflex irritability (Grimace) - Muscle tone (Activity) - Respiratory effort (Respiration)
Menarche is
- First menstrual period - Often begins just after the peak of adolescent growth spurt, at approximately age 12
FLACC scale
- Five categories (face, legs, activity, cry, and consolability) - 2 months to 7 yrs of age - a behavioral pain assessment scale used for nonverbal or preverbal patients who are unable to self-report their level of pain
Palpate sinuses
- Frontal sinus is above eyes - Maxillary sinus is below eyes
Types of tonsils
0 = no tonsils 1+ = visible 2+ = halfway between uvula and tonsilar pillars 3+ = nearly touching uvula 4+ = touching each other
A woman at 10 weeks of gestation seen in the prenatal clinic with presumptive signs and symptoms of pregnancy likely has which of the following?
Amenorrhea
Which technique is used for palpating lymph nodes?
Apply gentle pressure over the nodes with the pads of the fingers.
Tonic neck reflex
Arm & leg extend on side to which head turns
With the patient in a supine position, how does a nurse test the external rotation of the patient's right hip?
Asking the patient to place the right heel on the left patella
What does BUBBLEHEE stand for?
B-Breasts U-Uterus B-Bowel B-Bladder L-Lochia E-Episiotomy H-Hemorrhoids E-Edema E-Emotions
Expected changes during pregnancy (Breasts)
Become full & tender; enlarge; nipples & areolae more prominent; mammary veins become engorged
Scant amount
Blood only on tissue when wiped or less than 1 inch stain on peripad
Musculoskeletal assessment inspection expected outcomes
Body symmetric, straight spine, knees straight line (hips and ankles), feet flat, forward
How does the nurse assess a patient's consensual reaction?
By shining a light into the right eye and observing the papillary reaction of the left eye.
0/5 None (0), 0%
Complete absence of visible and palpable muscle contraction.
2/5 Poor (P), 25%
Complete range of joint motion possible only with the joint supported by the nurse to eliminate the force of gravity and without any manual resistance from the nurse.
3/5 Fair (F), 50%
Complete range of joint motion possible only without manual resistance from the nurse.
When an adolescent patient appears reluctant to discuss sensitive issues with the parent present, which of the following is the nurse's most appropriate intervention?
Create time at the end of the interview when the adolescent is alone with the nurse.
Expected changes during pregnancy (Reproductive)
Fundus becomes palpable; vagina, vulva, and cervix take on bluish color
The cracking noise heard in a patient's joint with movement is known as which of the following?
crepitus
external rotation of hip
crossing leg over to opposite knee
A patient is diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. Which of the following types of isolation precaution is most appropriate for this patient?
droplet
What is the most effective way to reduce the transmission of infections?
hand hygiene practices
A forward curvature in the thoracic spine is known as which of the following?
kyphosis
Which of the following hold bones to bones?
ligaments
Which of the following types of lochia should the nurse expect to find when assessing a woman who is one day postpartum?
lochia rubra
Uterus involution refers to
the process where your pregnant uterus (womb) returns to the way it was before pregnancy
The allergic salute refers to
the upwards swipe of the fingers or palms of the hands, along the tip of the nose, while sniffling in
Where should the fundus be immediately after delivery?
the uterine fundus is palpable at or near the level of the maternal umbilicus
Six bones of the cranium
one frontal, two parietal, two temporal, and one occipital are fused together
pH for pathogens to survive
pH: 5-7
vertigo
patient feels like the world is spinning around them
dizziness
patient feels off-balance, feels like they're going to fall down/pass out
hyperextension of hip
patient lays in prone position and lift their leg
Enophthalmos is
the displacement of the eyeball into the eye socket, making it appear sunken or smaller
Fundal height is
the distance from your pubic bone (symphysis pubic) to the top of your uterus (fundus)
Signs of Respiratory Distress Syndrome (RDS)
- Coughing - Stridor - Grunting - Retractions - Nasal flaring
RR for newborn
30-60
5/5 Normal (N), 100%
Complete range of joint motion against both gravity and full manual resistance from the nurse.
4/5 Good (G), 75%
Complete range of joint motion against both gravity and moderate manual resistance from the nurse.
BP for toddler
S: 80-112 D: 50-80
Nasal flaring is a hallmark sign of...
respiratory stress in an infant
Palmar erythema
unusual redness of the palms of the hands sometimes seen in pregnancy
full-term pregnancy
37-42 weeks
The nurse observes tonsils that are erythematous with white exudate. The tonsils are enlarged and displace the uvula as they touch each other. This rating of the tonsils would be documented as:
4+ bilaterally
HR for adolescent
60-90
Spine is composed of
7 cervical, 12 thoracic, 5 lumbar, and 5 sacral vertebrae
Examination of spine expected outcome
75 degrees of flexion while touching toes 30 degrees back from neutral with hyperextension 35 degrees lateral flexion (Full ROM of the spine)
HR for school age
75-100
HR for toddler
90-140
Endometriosis is
A disorder in which tissue that normally lines the uterus grows outside the uterus
Expected changes during pregnancy (Cardiovascular)
Increased cardiac workload (blood volume increases 1500 mL); heart shifts upward & forward; varicosities & edema in lower extremities
Palmar reflex
Infant grasps finger
Rooting Response reflex
Infant turns head in direction of stimulus and opens mouth
Expected changes during pregnancy (Urinary)
Nocturia & urinary frequency
The nurse testing the patient's muscle strength finds the patient has full range of motion with gravity. How would the nurse document this finding?
Normal or 5/5
After assessing a patient's eyes, all expected findings are observed. How should the nurse document these findings?
PERRLA
Step in place reflex
Paces forward using alternate steps
Expected changes during pregnancy (Respiratory)
Periodic shortness of breath; respiratory rate may increase; thoracic cage widens
Lochia serosa
Pinkish brown - approximately days 4-10
Ears inspection expected outcome
Pinna should directly align with outer canthus of the eye, vertical position with no more than 10 degrees
By the child is 7 or 8 years of age, the __ can be used to test visual acuity
Snellen chart
Test visual acuity (distant vision) by using
Snellen's chart
Goodell's sign
Softening of cervix
Hegar's sign
Softening of the lower uterine segment
Moro reflex
Startles to loud noise—abducts and extends arms and legs
Sucking reflex
Sucking motion follows with lips and tongue when lips touched
The student nurse is studying the changes a woman goes through during pregnancy. The student nurse knows that which body system undergoes the most dramatic physiologic changes during pregnancy?
The cardiovascular system
What are the characteristics of lymph nodes in patients who have an acute infection?
The lymph nodes are enlarged and tender.
Plantar reflex
Toes flex down to grasp
Characteristics of lymph nodes that may indicate malignancy
Unilateral Hard Asymmetric Fixed Nontender
Children are ___ until about the age of 7
abdominal breathers
Exophthalmos is
abnormal protrusion of the eyeball
Where are the frontal sinuses located?
above the eyebrows
profuse clear, watery nasal discharge can indicate
allergies
Chloasma
also known as melasma or the "mask of pregnancy," is a pigmentation disorder of the skin characterized by darker skin patches that primarily affect the face and other sun-exposed areas
Apgar scoring is
an assessment of five indications of a newborn's physiologic state: heart rate, respiratory effort, muscle tone, reflex irritability, and color at 1 and at 5 min following birth
Consensual response is
any reflex observed on one side of the body when the other side has been stimulated ex: the change in pupil size in the eye opposite to the eye to which the light is directed
Barlow and Ortolani maneuvers
- Screen for developmental dysplasia of the hip - There should be no clicking sound
The fundus will decrease by ___ per day
1 cm
A patient who has been in the hospital for several weeks is about to be discharged. The patient is weak from the hospitalization and asks the nurse to explain why this is happening. What is the nurse's best response?
"Your immobility in the hospital is known as deconditioning."
Appropriate communication with school-age child (6-12)
- Determine child's understanding of illness - Dispel myths/fears - Give child opportunity to speak for themselves - Allow/encourage children to communicate their needs - Provide information in clear terms - Be aware that child may respond to third-person prompts
Appropriate communication with toddler (1-3 yrs)
- Allow the child to complete a thought without interruption - Say specifically what you want the child to do - Do not offer a choice if there really is none - Speak at child's eye level - Use parallel play or toys to teach - Expect child will not understand time or "why"
Acrocyanosis means
- Bluish discoloration of the extremities due to decreased amount of oxygen delivered to the peripheral part - Can last for 12-24 hrs
Musculoskeletal assessment palpation expected outcomes
- Bones nontender - joints or muscles same temp as tissue - no tenderness or edema - firm muscles
Musculoskeletal assessment palpation variances
- Bones tender - joints or muscles warmer then tissue, with tenderness and/or edema - muscle atrophy or muscle hypertrophy
Probable signs of pregnancy
- Chadwick's sign - Goodell's sign - Hegar's sign - Ballottement - Positive pregnancy test (hCG) - Serum - Urine
Appropriate communication with preschooler (3-6 yrs)
- Keep instruction brief for short attention span - Use simple, direct language - Speak with a simple vocabulary - Make learning fun - Allow child to act out or express thoughts/feelings - Separate fantasy from reality
Examination of the knees variances
- Knees unaligned with tibia; ankle with decreased medial or lateral deviation - Deformities of the knee: genu valgum (knock-kneed) & genu varum (bowlegged)
Abdomen characteristics (pregnancy)
- Linea nigra - Striae gravidarum - Venous patterns - Fundal height - Fetal heart sounds
Common primary lesions in newborns
- Milia (clogged sebaceous glands) - Erythema toxicum (rash) - Mongolian spot
Meconium is
- Newborn's first poop - Sticky, thick, dark green poop is made up of cells, protein, fats, and intestinal secretions, like bile
Wong-Baker Faces Pain Rating Scale
- Pain scale for young children and is often described as suitable for children aged 3 to 18 years
Hourly rounding (Four P's)
- Position - Possessions - Pain - Potty
Types of signs of pregnancy
- Presumptive - Probable - Positive
Alterations in musculoskeletal system (pregnancy)
- Progressive lordosis - Waddling
Positive consequences of mobility
- Purposeful movement - Changing position and/or location without pain or discomfort
Appropriate communication with adolescent (12-20 yrs)
- Show respect by listening and explaining clearly - Allow for more independence - Give privacy and opportunity for confidentiality - Help adolescents trust adults by being honest about their treatment - Use peer support when possible - Never use "baby" voice - Speak as to another adult - Provide space for questions
Appropriate communication with infant (birth-1 yr old)
- Speak softly - Communicate through touch - Avoid overstimulation
Examples of assistive devices when patients unable to maintain proper positioning
- Trochanter rolls/towels - Lift sheets - Trapeze bar
Positive signs of pregnancy
- Visualization of fetus by ultrasound - Auscultation of fetal heart tones - Doppler - Fetoscope - Palpation of fetal movements - Observable fetal movements
Examples of assistive devices
- Walkers - Canes - Crutches
Negative consequences of mobility
- Weakness or loss of function - Patient Injury - Pressure Ulcers - Contractures
Around 37-40 weeks, the fundal height moves down about 4cm? Why?
- body is preparing for birth - baby has settled down to pelvic cavity
Presumptive signs of pregnancy
- breast changes - amenorrhea - nausea or vomiting - urinary frequency - quickening (fetal movement)
Bursae are
- small sacs in the connective tissues adjacent to selected joints - lined with synovial membrane containing synovial fluid, which acts as a lubricant to reduce friction
flexion of knee
- standing position - bring foot up
hyperextension of knee
- standing position - hyperextend leg from midline (foward)
Neonatal infant pain scale (NIPS)
- used for infants who are greater than 33 1/2 weeks gestation
RR for adolescent
12-16
HR for newborn
120-160
RR for school age
18-30
By age 5/6 years old, the ratio of AP: lateral diameter is
1:2
pre-term pregnancy
20-36 weeks
Visual acuity snellen chart expected outcome
20/30 or better
Ideal temperature for pathogens to survive
20° to 43° C or 68° to 109° F
RR for toddler
24-40
Where should the fundus be 2 days after birth?
2cm below the belly button
Ptosis is
Drooping of the eyelid
Characteristics of lymph nodes that may indicate infection
Enlarged Tender Firm Moveable
Pregnancy schedule of appointments
Every 4 weeks up to 28 weeks, every 2 weeks from 28 to 36 weeks, and weekly after 36 weeks
When a nurse asks a patient to place the right arm behind the head, the nurse is testing for which range of motion?
External rotation and abduction of the shoulder
Babinksi reflex
Fans toes when lateral surface of sole is stroked
While assessing the range of motion of the patient's knee, the nurse expects the patient to be able to perform which movements?
Flexion, extension, and hyperextension
A woman comes to the office for her first prenatal visit. She reports a history of one miscarriage at 10 weeks gestation, one live birth at 35 weeks, and one live birth at 38 weeks. She brought her two living children into the office with her. What is her GTPAL?
G-4, T-1, P-1, A-1, L-2
Acronym for obstetric history
GTPAL - Gravity (# of pregnancies including current pregnancy) - Full-Term births - Preterm births - Abortions (spontaneous/elective) - Living children
During symptom analysis, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates vertigo?
It seemed as if the room was spinning around
Expected changes during pregnancy (Integumentary)
Itching & reddened appearance of hands & feet; chloasma, linea nigra; striae gravidarum over abdomen & breasts
Light amount
Less than 4 inch stain on peripad
Moderate amount
Less than 6 inch stain on peripad
Expected changes during pregnancy (Musculoskeletal)
Lordosis & back discomfort; waddling gait & balance problems; separation of abdominal muscles
Palpation of lymph nodes expected outcome
May or may not be palpable, if palpable should be soft, mobile, nontender, bilaterally equal
When evaluating the reflexes of a newborn, the nurse notes after a loud noise, the newborn symmetrically abducts and extends his arms, his fingers fan out and form a C, and he has a slight tremor. The nurse should document this finding as a positive ______ reflex.
Moro's
1/5 Trace (Tr), 10%
Muscle contraction detectable but insufficient to move the joint even when the forces of both gravity and manual resistance have been eliminated.
The due date or expected date of confinement (EDC) can be calculated using...
Naegele's Rule - Determine first day of LMP, subtract 3 calendar months, add 7 days and 1 year
Expected changes during pregnancy (Gastrointestinal)
Nausea & vomiting; heartburn & constipation; hemorrhoids; swollen & bleeding gums
Ballottement
Presence of a floating object
Lochia rubra
Red - 1-3 days after delivery
BP for newborn
S: 60-90 D: 20-60
BP for school age
S: 84-120 D: 54-80
BP for adolescent
S: 94-139 D: 62-88
Heavy amount
Saturated peripad within 1 hour
Musculoskeletal assessment inspection variances
Scoliosis Kyphosis Lordosis
Chadwick's sign
Violet-blue color to cervix
Lochia alba
Yellow to white - day 10 to 6 weeks
Cephalohematoma is
a buildup of blood (hemorrhage) underneath a newborn's scalp
Erythema toxicum is
a common rash seen in full-term newborns
Where should the fundus be at 20 weeks gestation?
at about the bellybutton
Where should the fundus be 1 hour after birth?
at the belly button
At 7 days postpartum, the fundus should be
at the symphysis pubis
Where should the fundus be at 36 weeks?
at xiphoid process
For children less and up to age 5, take temperature by
axillary or temporal
thick green/yellow nasal discharge can indicate
bacterial
By 10-14 days postpartum,...
can't palpate uterus
To examine musculoskeletal system, use a...
cephalocaudal organization with side-to-side comparisons for examining bones, muscles, and joints
Subinvolution is
failure of uterus to revert to a pre-pregnant state through gradual reduction in size and placement
Lanugo is
fine, soft immature hair on newborns
Where are preauricular lymph nodes located?
in front of the ear
bulging fontanel may indicate
increased intracranial pressure
Which of the following best describes adduction of the hip or shoulder?
moving a limb toward the body and swinging across the front of the body
eversion of ankle/foot
point toes away the body
plantar flexion of foot
point toes toward the ground
inversion of ankle/foot
point toes towards the body
dorsiflexion of foot
point toes towards the sky
radial deviation of wrist
pointing fingers in (fingers point near the body)
ulnar deviation of wrist
pointing fingers out (fingers point away from body)
When taking tympanic temperature for a child over 3 years old, you should...
pull earlobe up
When taking tympanic temperature for a child less than 3 years old, you should...
pull their earlobe down
The examiner shines a penlight on a patient's left pupil. Which immediate response is expected with the right pupil?
pupil constriction
internal rotation of shoulder
put both of hands behind their back
external rotation of shoulder
put both of hands behind their head
internal rotation of hip
put knee up and allow it to fall toward body
After about six weeks, the uterus...
returns to its pre-pregnancy size
The "white" of the eye is called the ______.
sclera
Where should the fundus be at 12 weeks?
should be above the symphysis pubis
Tendons are
strong, nonelastic cords of collagen located at the ends of muscles to attach them to bones
Caput succedaneum
swelling of the scalp in a newborn
A 4-year-old child had a tonsillectomy. Which of the following techniques is most appropriate for the nurse to assess this patient's pain?
the Wong/Baker FACES rating scale
Anisocoria is
when your eye's pupils are not the same size
After 20-30 weeks, the fundal height...
will reflect weeks of pregnancy (+/-) 2cm