Prep-U Assessing Children: Infancy Through Adolescence
The nurse is assessing a 4-year-old child with complaints of pain and vomiting. Which of the following should the nurse suspect?
Appendicitis
A young child presents to the emergency department exhibiting intercostal retractions and abdominal breathing. What is the nurse's priority action?
Apply oxygen via nasal cannula
The nurse assesses the respiratory rate of a 5-year-old boy. Which finding would indicate to the nurse that his rate is within the age-appropriate range for this child?
24 breaths/minute
The parent of a 2 year old is concerned her child is talking but she cannot understand her. The nurse explains that this should occur by what age?
3
The nurse is assessing the heart rate of a 7-month-old infant. The nurse documents which finding as normal?
110 beats per minute
The nurse is participating in a vision-screening program for children age 3 to 10 years. The nurse would expect a child to have 20/20 vision at what age?
6 to 7
A mother visits the clinic for a routine visit with her 5-year-old son. The mother asks the nurse when the child's permanent teeth will erupt. The nurse should explain to the mother that permanent teeth usually begin to erupt by age
6 years
A mother voices concern about the amount of time her school-age child sleeps. When responding to the mother, the nurse understands that this age group sleeps an average of how many hours each night?
8 to 9.5
The Moro reflex is
A response to sudden stimulation or an abrupt change in position
A nurse is conducting a workshop with a group of adults who are enrolled in a parenting class. What would the nurse emphasize as important in helping the school-age child achieve the psychosocial task of industry and avoid inferiority?
Acknowledge accomplishments
A nurse should implement which important criteria to promote an effective nurse-parent communication when conducting a parent interview as a part of the child assessment?
Allow privacy for interview
Which child would the nurse suspect as having a developmental delay?
An 11-month-old who does not pull himself to a standing position
A nurse assigns an Apgar score to a newborn baby at 5 minutes after delivery. Which parameter should the nurse recognize as an abnormal finding?
Apical pulse is less than 100 beats per minute
A 4-year-old boy is brought to the emergency department by his parents, who state that he has been crying and saying his "tummy hurts." Which method would be most appropriate for the nurse to initially assess the problem?
Ask the child to point with one finger where it hurts
The nurse assesses the respirations of a 2-week-old infant and identifies periods of apnea lasting longer than 20 seconds. What should the nurse do next?
Assess the apical heart rate
Which action by the nurse demonstrates the correct technique to assess for hip dysplasia?
Assess the symmetry of the gluteal fold
A school nurse plans to test hearing acuity in students who range between kindergarten and sixth grade. What would be most appropriate method?
Audiometry
During examination of a newborn, the nurse strokes the lateral edge and ball of the newborn's foot so that the toes fan. What reflex is the nurse eliciting from this action?
Babinski
The nurse is caring for a newborn after vaginal delivery. The nurse assesses a heart rate of 172 beats/min, nasal flaring, sternal retractions, cyanosis, and grunting with respirations. What intervention should the nurse anticipate?
Bag and mask or mechanical ventilation
When teaching parents about the development of secondary sex characteristics in female children, which of the following would the nurse include as usually appearing first?
Breast buds
The student nurse reports that the breath sounds of an infant are loud and harsh. How should the nurse best respond?
Breath sounds in infants will be louder and harsher due to a thinner chest wall
A mother of a 4 year old child calls the clinic nurse because her child has swallowed some type of cleaning agent. What is the nurse's best response?
Call the Poison Help Line #1-800-222-1222 for instructions on treatment.
During the health assessment interview, which question should the nurse ask the parents of a preschooler to determine the child's level of motor development?
Can your child run, hop, and skip
A nurse is providing an in-service presentation to a group of new pediatric nurses and reviewing differences in assessment of children and adults. When describing the heart sound typically auscultated in children in comparison to an adult, which characteristic would the nurse describe?
Children typically have higher pitched heart sounds
A nurse assesses the pulses of an infant and notes a weakness of the femoral pulses. Which of the following would the nurse suspect?
Coarctation of the aorta
Tommy, an 18-month-old, is seen in the clinic for otitis media. The nurse notes that Tommy coos and babbles but does not say distinct words. Which nursing diagnosis is most appropriate?
Delayed growth and development
The nurse has identified a need to discuss sexuality with a 15-year-old client. How should the nurse best plan this aspect of the health interview?
Discuss the matter when a parent is not present
A nurse notes the respiratory rate of a 2-year-old to be 28 breaths per minute. What is an appropriate action by the nurse in regards to this finding?
Document the finding in the child's chart
The nurse notes that a sleeping newborn's heart rate is 102 bpm. What action should the nurse take first?
Document the heart rate
A mother of a 1-month-old calls the health care clinic and tells the nurse that she is concerned because when her infant cries, the top of his head seems to push out. What question should the nurse ask the mother to gather more information about this finding?
Does the bulging stop when the baby stops crying?
A teacher refers a child to the school nurse, concerned that the child's speech is difficult to understand and not at the same level as other children in the age group. What information would be a priority for the nurse to obtain from the parent of this child?
Does the child have a history of frequent ear infections?
A nurse assesses a newborn with bruising on the head. How should the nurse document this finding?
Ecchymoses
While assessing a newborn infant, the nurse observes yellow-white retention cysts in the newborn's mouth. The nurse should explain to the infant's parents that these spots are usually indicative of
Epstein pearls
Which action by the nurse demonstrates the correct technique of assessing for the popliteal angle?
Flex thigh on top of the abdomen
When the nurse palpates the neck of an infant, crepitus at the right shoulder area is noted. The infant also exhibits decreased movement in the right arm. What would the nurse suspect?
Fractured clavicle
The nurse bends a newborn's wrist towards the forearm until resistance is met. For what is the nurse assessing this newborn?
Gestational age
The nurse is preparing to assess the gross motor development of a 4-year-old child. The nurse should ask the child to
Hop on one foot
A nurse inspects the anus of a newborn. Which of the following findings should be referred immediately to a specialist?
Imperforate anus
As a nurse is examining a 13-year-old boy, she notices a strong body odor. Which developmental change best explains this finding?
Increased apocrine gland activity
A mother brings her two-month-old infant to the health care facility with a high temperature. Which action by the nurse demonstrates the proper way to safely measure the rectal temperature in the baby?
Insert the thermometer no more than 2 cm
It is often difficult to assess the location of pain in a child because generally children cannot
Isolate their pain
The mother of an 8 year old girl expresses concern about feeling a lump at each of the child's areolas. What is the nurse's best response?
It is likely a breast bud which is a normal finding at this age
The nurse assessing a 3-month-old child in the clinic asks the mother if she has childproofed the home. For what would the nurse be assessing when asking this question?
Lifestyle-related risk factors
While performing an assessment on a 14 year old, the nurse notes the child has limited range of motion of the neck. The nurse recognizes this could be caused by what?
Meningitis
A nurse measures an 18-month-old child's head circumference (HC) and finds that it is in the 3rd percentile. Which of the following conditions should the nurse suspect in this child?
Microcephaly
A nurse assesses a newborn of African American descent and observes a bluish-pigmented area on the sacrum. The nurse recognizes this as what type of skin variation?
Mongolian spot
The nurse is assessing a newborn infant who currently has nasal congestion and rhinorrhea. What would the nurse consider when analyzing these data?
Nasal congestion can impair oxygenation because infants are nose breathers
Which procedure demonstrates correct placement of a tape measure by a nurse when measuring the chest circumference of a 12-month-old infant?
Nipple line
A nurse auscultates the chest of a newborn. The nurse hears breath sounds that are loud and harsh. Which of the following does this finding most likely indicate?
Normal
Which method should a nurse use when assessing respirations in a newborn?
Observe the respiratory effort for one full minute
The nurse is preparing to perform an assessment on a toddler. Where should the nurse position the child?
On the parent's lap
A nurse assesses an 8-month-old infant and observes an irregular shape to the infant's head. What assessment should the nurse perform next?
Palpate anterior fontanelle
A nurse is assessing the hip and legs of a newborn. The nurse suspects congenital hip dysplasia based on which of the following?
Positive Ortolani's sign
While assessing the head and neck of an 11 year old child, the nurse palpates several tender and swollen lymph nodes. What is the nurse's best action?
Prepare to collect blood to analyze white blood cell count
The mother of a newborn has struggled to effectively breastfeed her daughter. The mother has received instruction from a lactation specialist on proper breastfeeding techniques, but the baby will not latch on. She has decided to bottle feed the baby at least for now. Also, when assessing the infant's musculoskeletal system, the nurse found unequal gluteal folds and limited hip abduction. Which of the following should be the priority nursing conclusion?
RC: Hip displacement
A nurse is presenting a class for new parents about infant care. Which of the following positions would the nurse emphasize as important in decreasing the risk of sudden infant death syndrome?
Supine
A nurse is reviewing an infant's Apgar score. Which of the following areas was assessed during the calculation of the score?
Reflex irritability
During the health assessment interview, a nurse should ask the parents of a 9-year-old male questions related to which activities to elicit age-related development of psychosexual stage?
Relative sexual indifference and interaction with same-sex peers
A nurse is evaluating reflexes in a newborn. The nurse gently strokes the cheek, and the newborn turns toward the stimulus and opens the mouth. What reflex is the nurse testing?
Rooting
Anticipatory guidance for parents of newborns and infants focuses primarily on
Safety
Your client is a 15-year-old male. His testes and scrotum are enlarged and the scrotal skin is darkened. His pubic hair is coarse and curly but does not extend to the thighs. What Tanner stage would you assign to this client?
Stage 4
A new mother rings her call bell after giving birth to a healthy infant 18 hours earlier. The client states that her infant "looks like she has milk coming out of her nipples." How should the nurse best interpret this phenomenon?
This is a normal finding that results from the hormonal stimulation
The nurse is assessing a young adolescent female client using Tanner Sexual Maturity Rating for Breast Development. The nurse determines that the client has enlargement of the breasts and areolae, with no separation of contours. The client is in Tanner Stage
Three
A nurse recognizes that which deep tendon reflex is absent in children until the age of 6?
Triceps
The nurse manager in a pediatric clinic should intervene when observing which assessment technique by a staff nurse?
Using the pneumatic bulb while trying to visualize the tympanic membrane
What question should the nurse ask in order to assess an adolescent's risk factors for obesity and deficient nutritional status?
What do you eat in a typical day
The nurse is assessing a school age client for a school physical examination. The client is a recent immigrant to the United States; this is the client's first visit to the clinic. When doing the initial assessment, the nurse would assess their nutrition by asking what questions? (Select all that apply.)
What food do you eat for the last meal of the day? Is family food prepared at home? With whom do you eat?
The nurse completes the health history of a 15-year-old client and the mother. What should the nurse do before beginning the physical examination?
ask the mother to leave the room
